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For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","confirm_attestation":true,"attester_name":"Thomas Bowden"},"standard_charge_information":[{"description":"Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) 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","code_information":[{"code":"616","type":"RC"},{"code":"70015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25858.060,"maximum":25858.060,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25858.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":25858.060,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PROSTATECTOMY WITH CC ","code_information":[{"code":"666","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12358.980,"maximum":12741.220,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12358.980,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12741.220,"methodology":"fee schedule"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75820","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":322.840,"maximum":376.420,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":322.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":373.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":376.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":338.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":376.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":376.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":373.780,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, femur, shaft or supracondylar; with fixation ","code_information":[{"code":"27450","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Prothrombin time; substitution, plasma fractions, each ","code_information":[{"code":"85611","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6.480,"maximum":16.510,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":6.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":7.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.510,"methodology":"fee schedule"}]}]},{"description":"Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection ","code_information":[{"code":"87250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.430,"maximum":429.650,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19.560,"methodology":"fee schedule"},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":17.430,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":19.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":19.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":27.380,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":34.870,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":429.650,"methodology":"fee 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or hematoma ","code_information":[{"code":"27603","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Replacement, tricuspid valve, with cardiopulmonary bypass ","code_information":[{"code":"33465","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIGESTIVE MALIGNANCY WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Galsulfase injection ","code_information":[{"code":"9224","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":513.860,"maximum":916.110,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":513.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":513.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":524.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":719.400,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":916.110,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":524.140,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":524.140,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":513.860,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":534.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":524.140,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":513.860,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC ","code_information":[{"code":"097","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard 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","code_information":[{"code":"32820","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lymphangiography, extremity only, bilateral, radiological supervision and interpretation ","code_information":[{"code":"359","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":51937.800,"maximum":51937.800,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":51937.800,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone graft, any donor area; major or large ","code_information":[{"code":"20902","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) ","code_information":[{"code":"307","type":"RC"},{"code":"81190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":304.650,"maximum":776.170,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":768.770,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency ","code_information":[{"code":"481","type":"RC"},{"code":"58674","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin-embedded (FFPE) tissue, saliva, buccal swabs or cell ","code_information":[{"code":"0265U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9007.690,"maximum":22949.080,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9007.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22730.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10508.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9457.250,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj secretin synthetic hu ","code_information":[{"code":"01700","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":39.230,"maximum":40.440,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":39.230,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or 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for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11552.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10396.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":11552.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11552.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18354.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform exp 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, elbow; with synovectomy ","code_information":[{"code":"24102","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; with chest wall reconstruction ","code_information":[{"code":"32504","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; init ","code_information":[{"code":"37238","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; aortoceliac or aortomesenteric ","code_information":[{"code":"35531","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna ","code_information":[{"code":"25455","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HYPERTENSION WITH MCC ","code_information":[{"code":"148","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; 2 views ","code_information":[{"code":"404","type":"RC"},{"code":"73521","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Trabeculotomy by laser, including optical coherence tomography (OCT) guidance ","code_information":[{"code":"0730T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Collagen cross links, any method ","code_information":[{"code":"82523","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.640,"maximum":410.350,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":18.680,"methodology":"fee schedule"},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":16.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":18.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":26.150,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":33.300,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":410.350,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":410.350,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":18.680,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":18.740,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":19.430,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":19.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":18.680,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":16.970,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, internal auditory meati, complete ","code_information":[{"code":"401","type":"RC"},{"code":"70134","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17563.220,"maximum":17563.220,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":17563.220,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17563.220,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2880.000,"maximum":29291.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10972.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8299.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2880.000,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3359.000,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3359.000,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3023.100,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3359.000,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":10972.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":11191.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3359.000,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3359.000,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":15361.190,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":14487.600,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":11191.730,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":10972.280,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":11411.170,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10730.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":10972.280,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8541.630,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"126","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":855.130,"maximum":872.230,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":855.130,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":872.230,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Revision of ileostomy; simple (release of superficial scar) (separate procedure) ","code_information":[{"code":"44312","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; ","code_information":[{"code":"33774","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material ","code_information":[{"code":"409","type":"RC"},{"code":"73721","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical 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","code_information":[{"code":"0925T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of nonunion or malunion, tibia; with sliding graft ","code_information":[{"code":"27722","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal uret ","code_information":[{"code":"481","type":"RC"},{"code":"52649","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of enterocele, vaginal approach (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"57268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical prostatectomy, simple subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy), includes robot ","code_information":[{"code":"481","type":"RC"},{"code":"55867","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine; thoracic, minimum of 4 views ","code_information":[{"code":"409","type":"RC"},{"code":"72074","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":59.470,"maximum":69.340,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":59.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":68.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":69.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":62.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":69.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":69.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":68.850,"methodology":"fee schedule"}]}]},{"description":"Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial ","code_information":[{"code":"30905","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"325","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. 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","code_information":[{"code":"22810","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":67500.000,"maximum":87326.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":67500.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":87326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":78719.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":70847.100,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":78719.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":78719.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":87326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus ","code_information":[{"code":"64681","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) ","code_information":[{"code":"31051","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"44401","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venograp ","code_information":[{"code":"0797T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) ","code_information":[{"code":"33496","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COMPLICATIONS OF TREATMENT WITHOUT CC/MCC ","code_information":[{"code":"203","type":"RC"},{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion ","code_information":[{"code":"10007","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 1 view ","code_information":[{"code":"402","type":"RC"},{"code":"73501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_percentage":23.40,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3850 reimbursement is 23.4% of aggregated billable gross charges. If aggregated billable gross charges are less than $3850 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_percentage":21.10,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3850 reimbursement is 21.1% of aggregated billable gross charges. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_percentage":23.40,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3850 reimbursement is 23.4% of aggregated billable gross charges. If aggregated billable gross charges are less than $3850 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_percentage":23.40,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3850 reimbursement is 23.4% of aggregated billable gross charges. If aggregated billable gross charges are less than $3850 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Closed treatment of carpal scaphoid (navicular) fracture; without manipulation ","code_information":[{"code":"25622","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Respiratory motion management simulation (List separately in addition to code for primary procedure) ","code_information":[{"code":"341","type":"RC"},{"code":"77293","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10959.330,"maximum":10959.330,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":10959.330,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10959.330,"methodology":"fee schedule"}]}]},{"description":"REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED ","code_information":[{"code":"361","type":"RC"},{"code":"49566","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) ","code_information":[{"code":"33412","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; ","code_information":[{"code":"50970","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, wrist; 2 views ","code_information":[{"code":"322","type":"RC"},{"code":"73100","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.740,"maximum":51.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":51.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":45.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":51.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":51.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.640,"methodology":"fee schedule"}]}]},{"description":"Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of po ","code_information":[{"code":"33224","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), ","code_information":[{"code":"34704","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Red cell survival study ","code_information":[{"code":"340","type":"RC"},{"code":"78130","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":561.540,"maximum":654.740,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":561.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":650.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":654.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":589.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":654.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":654.740,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"116","type":"RC"},{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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","code_information":[{"code":"312","type":"RC"},{"code":"88165","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":69.450,"maximum":176.940,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":69.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":175.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":81.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":72.920,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":81.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":81.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":176.940,"methodology":"fee schedule"}]}]},{"description":"ATHEROSCLEROSIS WITH MCC 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10925.200,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8388.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11120.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":30519.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12968.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":11671.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12968.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":10925.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":11143.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12968.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35354.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":15295.280,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":14416.520,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":11143.700,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":10925.200,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":11362.210,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10684.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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excised diameter 0.5 cm or less ","code_information":[{"code":"11420","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, facial bones; 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"}]}]},{"description":"Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur ","code_information":[{"code":"27185","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nuclear Matrix Protein 22 (NMP22), qualitative ","code_information":[{"code":"301","type":"RC"},{"code":"86386","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.830,"maximum":91.280,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":35.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":90.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":37.620,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial ","code_information":[{"code":"481","type":"RC"},{"code":"61320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chromosome analysis; analyze 20-25 cells ","code_information":[{"code":"310","type":"RC"},{"code":"88264","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":237.880,"maximum":606.060,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":237.880,"methodology":"fee 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","code_information":[{"code":"490","type":"RC"},{"code":"55865","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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","code_information":[{"code":"307","type":"RC"},{"code":"80186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.640,"maximum":57.670,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":23.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":26.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":57.670,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic 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","code_information":[{"code":"329","type":"RC"},{"code":"74210","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":350.240,"maximum":408.360,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":350.240,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":405.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":408.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":367.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":408.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":408.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":405.500,"methodology":"fee schedule"}]}]},{"description":"Level 3 Extraocular, Repa ","code_information":[{"code":"05503","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2461.850,"maximum":2537.990,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2461.850,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2537.990,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coagulation time; Lee and White ","code_information":[{"code":"307","type":"RC"},{"code":"85345","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.720,"maximum":19.660,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.660,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC ","code_information":[{"code":"195","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Arthroplasty, intercarpal or carpometacarpal joints; suspension, including transfer or transplant of tendon, with interposition, when performed ","code_information":[{"code":"25448","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score ","code_information":[{"code":"0113U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.200,"maximum":3185.160,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3154.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1312.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3185.160,"methodology":"fee schedule"}]}]},{"description":"Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5'-UTR-BMI1, CEP 164, 3'-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm ","code_information":[{"code":"0021U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":16698.510,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":1064.000,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1354.930,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16698.510,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16698.510,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":790.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; phalanx of toe ","code_information":[{"code":"28175","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":29291.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8881.670,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":6580.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8740.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":23987.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10193.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9173.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10193.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":8881.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9059.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10193.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":27788.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":12434.340,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":11331.050,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9059.300,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8881.670,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9236.940,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s) ","code_information":[{"code":"15730","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions ","code_information":[{"code":"306","type":"RC"},{"code":"87901","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":423.510,"maximum":1078.970,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":423.510,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1068.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":494.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":444.640,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement ","code_information":[{"code":"24331","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Blepharoplasty, upper eyelid; 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, b ","code_information":[{"code":"0016M","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5740.440,"maximum":14625.040,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5740.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14485.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6696.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":6026.940,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, pl ","code_information":[{"code":"44378","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC ","code_information":[{"code":"202","type":"RC"},{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOT ","code_information":[{"code":"837","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20366.830,"maximum":20996.730,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":20366.830,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":20996.730,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, 1 stage or first stage 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), in ","code_information":[{"code":"31647","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, chest; 4 or more views ","code_information":[{"code":"359","type":"RC"},{"code":"71048","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural r ","code_information":[{"code":"0338T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Addition to lower extremity, straight knee joint, heavy duty, each joint ","code_information":[{"code":"L2385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":190.310,"maximum":349.790,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":196.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":196.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":200.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":274.680,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":349.790,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":200.120,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":200.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":196.200,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":190.310,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":204.050,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":196.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":200.120,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":196.200,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC ","code_information":[{"code":"411","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT ","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":70180.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":16768.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":13597.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26059.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":68074.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30390.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":27351.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":30390.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":16768.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":17103.920,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30390.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70180.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":23475.970,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":23239.190,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":54936.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":63177.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":17103.920,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":29716.000,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":37145.000,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":24887.000,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":37145.000,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":37145.000,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":16768.550,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":17439.290,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16399.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":16768.550,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13993.610,"methodology":"fee schedule"}]}]},{"description":"Anoscopy; with biopsy, single or multiple ","code_information":[{"code":"46606","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (eg, ","code_information":[{"code":"360","type":"RC"},{"code":"69637","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Proton treatment delivery; intermediate ","code_information":[{"code":"618","type":"RC"},{"code":"77523","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46190.890,"maximum":46190.890,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":46190.890,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":46190.890,"methodology":"fee schedule"}]}]},{"description":"Transcatheter removal or debulking of intracardiac mass (eg, vegetations, thrombus) via suction (eg, vacuum, aspiration) device, percutaneous approach, with intraoperative reinfusion of aspirated bloo ","code_information":[{"code":"0644T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) ","code_information":[{"code":"88332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.520,"maximum":550.990,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":13.520,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":550.990,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":550.990,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13.790,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed ","code_information":[{"code":"321","type":"RC"},{"code":"77067","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":498.220,"maximum":580.900,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":498.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":576.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":580.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":522.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":580.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":580.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":576.830,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA WITH BRAIN OR SPINAL CORD IN ","code_information":[{"code":"128","type":"RC"},{"code":"B1801","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":23231.980,"maximum":23696.620,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":23696.620,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":23231.980,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":23231.980,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor VIII related antigen ","code_information":[{"code":"305","type":"RC"},{"code":"85244","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.590,"maximum":85.580,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":33.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":84.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":39.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":35.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":39.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":39.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":85.580,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, temporal bone, middle fossa approach ","code_information":[{"code":"369","type":"RC"},{"code":"69979","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy ","code_information":[{"code":"351","type":"RC"},{"code":"G6002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1921.000,"maximum":1921.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1921.000,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1921.000,"methodology":"fee schedule"}]}]},{"description":"Transurethral resection of bladder neck (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"52500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed ","code_information":[{"code":"490","type":"RC"},{"code":"61635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj, sutimlimab-jome, 10 ","code_information":[{"code":"09444","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":18.460,"maximum":19.030,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":18.460,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":19.030,"methodology":"fee schedule"}]}]},{"description":"Open treatment of mandibular fracture with external fixation ","code_information":[{"code":"21454","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16416.000,"maximum":19440.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Escharotomy; each additional incision (List separately in addition to code for primary procedure) ","code_information":[{"code":"16036","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC ","code_information":[{"code":"256","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"458","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon ","code_information":[{"code":"26418","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coracoacromial ligament release, with or without acromioplasty ","code_information":[{"code":"23415","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HYPERTENSION WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Colorectal cancer screening; colonoscopy on individual at high risk ","code_information":[{"code":"750","type":"RC"},{"code":"G0105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Periodontal mucosal grafting ","code_information":[{"code":"41870","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of patellar dislocation; requiring anesthesia ","code_information":[{"code":"27562","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less ","code_information":[{"code":"12051","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) ","code_information":[{"code":"304","type":"RC"},{"code":"82820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.940,"maximum":55.910,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":23.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":25.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":55.910,"methodology":"fee schedule"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY  IPF","code_information":[{"code":"134","type":"RC"},{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1137.060,"maximum":1159.800,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1137.060,"methodology":"fee schedule","additional_payer_notes":"Days 5. 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":4898.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8647.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of fibrous tuberosities, dentoalveolar structures ","code_information":[{"code":"41822","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm ","code_information":[{"code":"12052","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOU ","code_information":[{"code":"210","type":"RC"},{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"148","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY ","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":115862.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":43904.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":37137.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":93600.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":98241.300,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":43904.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":44782.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":61465.910,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":64210.490,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":100748.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":115862.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":44782.300,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":43904.220,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":45660.390,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":42938.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":43904.220,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":38219.510,"methodology":"fee schedule"}]}]},{"description":"Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical ","code_information":[{"code":"22110","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, ankle; complete, minimum of 3 views ","code_information":[{"code":"340","type":"RC"},{"code":"73610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination ","code_information":[{"code":"97163","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":96.490,"maximum":177.760,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":99.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":99.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":101.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":139.590,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":177.760,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":101.700,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":101.700,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":99.710,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":96.490,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":103.700,"methodology":"fee schedule"},{"payer_name":"Martin's Point 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos ","code_information":[{"code":"300","type":"RC"},{"code":"89251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.370,"maximum":625.130,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":619.160,"methodology":"fee 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each 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be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":" Behavioral Health Treatment/Services Partial Hospitalization - Less Intensive  Partial Full Day MH Adult","code_information":[{"code":"912","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":725.000,"maximum":725.000,"payers_information":[{"payer_name":"United Behavioral Health","plan_name":"BHCOMM","standard_charge_dollar":725.000,"methodology":"per diem"}]}]},{"description":"Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC ","code_information":[{"code":"210","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ANGINA PECTORIS ","code_information":[{"code":"127","type":"RC"},{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per 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","code_information":[{"code":"35276","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Caffeine ","code_information":[{"code":"80155","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":63.450,"maximum":161.650,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":63.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":160.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":74.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":66.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":74.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":74.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":161.650,"methodology":"fee schedule"}]}]},{"description":"Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including u ","code_information":[{"code":"19083","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystine and homocystine, urine, qualitative ","code_information":[{"code":"302","type":"RC"},{"code":"82615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.710,"maximum":40.020,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":16.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":18.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.020,"methodology":"fee schedule"}]}]},{"description":"Acetylcholine receptor (AChR), antibody identification by immunofluorescence, using live cells, reported as positive or negative ","code_information":[{"code":"0545U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":62.070,"maximum":158.130,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":62.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":156.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":72.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":65.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":72.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":72.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":158.130,"methodology":"fee schedule"}]}]},{"description":"Pericardiocentesis, including imaging guidance, when performed ","code_information":[{"code":"33016","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75984","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":192.600,"maximum":224.560,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":192.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":222.980,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":224.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":202.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":224.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":224.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":222.980,"methodology":"fee 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schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":147.060,"methodology":"fee schedule"}]}]},{"description":"Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"320","type":"RC"},{"code":"75774","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":277.150,"maximum":323.140,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":277.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":320.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":323.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":290.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":323.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":323.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":320.880,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of mandibular fracture with interdental fixation ","code_information":[{"code":"21453","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8702.100,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15364.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, anterior chamber of eye (separate procedure); medication ","code_information":[{"code":"490","type":"RC"},{"code":"66030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Factor viii recomb novoei ","code_information":[{"code":"01856","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.500,"maximum":1.550,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1.500,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1.550,"methodology":"fee schedule"}]}]},{"description":"Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple ","code_information":[{"code":"38570","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":42354.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":42354.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":66787.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of meningocele; larger than 5 cm diameter 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative ","code_information":[{"code":"81207","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":238.260,"maximum":607.020,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":238.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":601.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":277.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":250.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":277.950,"methodology":"fee 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schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.330,"methodology":"fee schedule"}]}]},{"description":"Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion ","code_information":[{"code":"361","type":"RC"},{"code":"69740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base, including occipital condylectomy, mastoidectomy, resection of C1-C3 vertebral body(s), decompres ","code_information":[{"code":"61597","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coagulation time; Lee and White ","code_information":[{"code":"305","type":"RC"},{"code":"85345","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.720,"maximum":19.660,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.660,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; axillary-axillary 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, with synovectomy, ankle; ","code_information":[{"code":"27625","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Level 3 Nerve Injections ","code_information":[{"code":"05443","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":915.860,"maximum":944.180,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":915.860,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KI ","code_information":[{"code":"0105U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1562.750,"maximum":3981.450,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1562.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3943.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1823.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1640.750,"methodology":"fee 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per 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","code_information":[{"code":"38120","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of fracture of orbit, except blowout; with implant ","code_information":[{"code":"21407","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC ","code_information":[{"code":"058","type":"MS-DRG"},{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, complete acute abdomen series, including 2 or more views of the abdomen (eg, supine, erect, decubitus), and a 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Splitting of blood or blood products, each unit 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tendon lengthening, upper arm or elbow, each tendon ","code_information":[{"code":"24305","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine; thoracic, 3 views ","code_information":[{"code":"409","type":"RC"},{"code":"72072","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":54.180,"maximum":63.170,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":54.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":63.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":56.850,"methodology":"fee 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","code_information":[{"code":"611","type":"RC"},{"code":"77074","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, lumbosacral; 2 or 3 views ","code_information":[{"code":"321","type":"RC"},{"code":"72100","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical 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M ","code_information":[{"code":"024","type":"RC"},{"code":"B1703","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":38740.630,"maximum":38740.630,"payers_information":[{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":38740.630,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Pregnancy-associated plasma protein-A (PAPP-A) ","code_information":[{"code":"305","type":"RC"},{"code":"84163","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.760,"maximum":63.070,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":25.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":28.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.070,"methodology":"fee schedule"}]}]},{"description":"Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells ","code_information":[{"code":"310","type":"RC"},{"code":"88275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.210,"maximum":214.540,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":212.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":98.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":88.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":98.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":98.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":214.540,"methodology":"fee schedule"}]}]},{"description":"Disarticulation of shoulder; ","code_information":[{"code":"23920","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"87430","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.650,"maximum":70.450,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":29.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":32.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.450,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograft ","code_information":[{"code":"24126","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_percentage":35.60,"standard_charge_algorithm":"Reimbursement will be 35.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_percentage":35.60,"standard_charge_algorithm":"Reimbursement will be 35.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Radiologic examination, spine, single view, specify level ","code_information":[{"code":"324","type":"RC"},{"code":"72020","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":87.170,"maximum":101.640,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":87.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":100.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":101.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":91.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":101.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":101.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":100.930,"methodology":"fee schedule"}]}]},{"description":"Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"61050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"204","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Frenoplasty (surgical revision of frenum, eg, with Z-plasty) ","code_information":[{"code":"41520","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vestibuloplasty; posterior, bilateral ","code_information":[{"code":"40843","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination; sternum, minimum of 2 views ","code_information":[{"code":"350","type":"RC"},{"code":"71120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) ","code_information":[{"code":"306","type":"RC"},{"code":"82595","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.640,"maximum":27.120,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":11.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":27.120,"methodology":"fee schedule"}]}]},{"description":"Percutaneous vertebral augmentations, first thoracic and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) ","code_information":[{"code":"761","type":"RC"},{"code":"C7507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation ","code_information":[{"code":"28546","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC ","code_information":[{"code":"119","type":"RC"},{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 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","code_information":[{"code":"40840","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed ","code_information":[{"code":"23680","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of mandibular fracture; without manipulation ","code_information":[{"code":"21450","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Activated Protein C (APC) resistance assay ","code_information":[{"code":"303","type":"RC"},{"code":"85307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.200,"maximum":64.210,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":26.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":64.210,"methodology":"fee schedule"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"061","type":"MS-DRG"},{"code":"130","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Thrombectomy, direct or with catheter; subclavian vein, by neck incision ","code_information":[{"code":"34471","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass ","code_information":[{"code":"33982","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions ","code_information":[{"code":"87901","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":229.370,"maximum":5656.500,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":257.450,"methodology":"fee schedule"},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":229.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":257.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":262.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":360.430,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":458.980,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5656.500,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5656.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":262.600,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":262.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":257.450,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":258.210,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":267.750,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":266.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":262.600,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":257.450,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":233.820,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hip, arthrography, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"73525","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":573.110,"maximum":668.220,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":573.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":663.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":668.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":601.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":668.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":668.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":663.540,"methodology":"fee schedule"}]}]},{"description":"Hydroxychloroquine ","code_information":[{"code":"304","type":"RC"},{"code":"80220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.660,"maximum":78.120,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":32.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":35.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.120,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve ","code_information":[{"code":"64430","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal ","code_information":[{"code":"360","type":"RC"},{"code":"55831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC ","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":46195.170,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13852.860,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":11727.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14529.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39877.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16945.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":15250.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":16945.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":13852.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":14129.920,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16945.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46195.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":19394.000,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18836.890,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":14129.920,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":13852.860,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":14406.970,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13548.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming ","code_information":[{"code":"490","type":"RC"},{"code":"62362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":37301.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20283.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37301.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23655.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":21289.500,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":23655.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23655.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37301.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability ","code_information":[{"code":"305","type":"RC"},{"code":"81458","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1721.250,"maximum":4385.250,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1721.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4343.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2007.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1807.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":2007.950,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection ","code_information":[{"code":"0088U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5197.250,"maximum":13241.130,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5197.250,"methodology":"fee 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","code_information":[{"code":"481","type":"RC"},{"code":"63251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Candida species panel (C. albicans, C. glabrata, C. parapsilosis, C. kruseii, C. tropicalis, and C. auris), amplified probe technique with qualitative report of the presence or absence of each species ","code_information":[{"code":"0068U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":234.630,"maximum":597.760,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":234.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":592.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":273.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":246.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":273.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":273.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":597.760,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump ","code_information":[{"code":"96425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":828.980,"maximum":829.510,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":829.510,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":828.980,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum ","code_information":[{"code":"300","type":"RC"},{"code":"87147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.520,"maximum":21.710,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.940,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious disease (genitourinary pathogens), DNA, 46 targets (28 pathogens, 18 resistance genes), RT-PCR amplified probe technique, urine, each ","code_information":[{"code":"0593U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1044.310,"maximum":2660.610,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1044.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2635.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1218.260,"methodology":"fee 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for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation ","code_information":[{"code":"29887","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not ","code_information":[{"code":"306","type":"RC"},{"code":"G0481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":257.590,"maximum":656.270,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":257.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":650.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":300.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":270.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":300.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":300.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":656.270,"methodology":"fee schedule"}]}]},{"description":"Venography, epidural, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75872","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":399.070,"maximum":465.300,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":399.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":462.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":465.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":418.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":465.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":465.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":462.040,"methodology":"fee schedule"}]}]},{"description":"Blood typing, serologic; antigen testing of donor blood using reagent serum, each antigen test ","code_information":[{"code":"86902","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10.450,"maximum":26.610,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10.970,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":26.610,"methodology":"fee schedule"}]}]},{"description":"Exploration of orbit (transcranial approach), with removal of lesion ","code_information":[{"code":"61333","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component ","code_information":[{"code":"23474","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton ","code_information":[{"code":"46060","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMATIC SPINAL CORD INJURY; M < 16.05 & A < 63.5 ","code_information":[{"code":"128","type":"RC"},{"code":"A0405","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":37625.060,"maximum":38377.560,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":38377.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":37625.060,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":37625.060,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy ","code_information":[{"code":"481","type":"RC"},{"code":"56631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm ","code_information":[{"code":"11446","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach ","code_information":[{"code":"33364","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery ","code_information":[{"code":"31241","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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nerve ","code_information":[{"code":"361","type":"RC"},{"code":"64408","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Necropsy (autopsy), limited, gross and/or microscopic; regional ","code_information":[{"code":"311","type":"RC"},{"code":"88036","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":173.350,"maximum":441.650,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":173.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":437.430,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":202.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":182.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":202.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":202.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":441.650,"methodology":"fee schedule"}]}]},{"description":"Antibody; Candida ","code_information":[{"code":"309","type":"RC"},{"code":"86628","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.760,"maximum":50.330,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":20.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":23.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.330,"methodology":"fee schedule"}]}]},{"description":"KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) ","code_information":[{"code":"301","type":"RC"},{"code":"81275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":317.900,"maximum":809.910,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":802.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":370.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":333.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":370.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":370.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":809.910,"methodology":"fee schedule"}]}]},{"description":"Excision tracheal stenosis and anastomosis; cervicothoracic ","code_information":[{"code":"31781","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype ","code_information":[{"code":"0419U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2197.870,"maximum":5599.550,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2197.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5546.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2563.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":2307.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":2563.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2563.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5599.550,"methodology":"fee schedule"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"084","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":29291.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9003.760,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":6894.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8882.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24377.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10358.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9323.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10358.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":9003.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9183.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10358.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28240.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":12605.260,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":11515.380,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9183.830,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9003.760,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9363.910,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8805.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":9003.760,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7095.140,"methodology":"fee schedule"}]}]},{"description":"Removal with reinsertion, non-biodegradable drug delivery implant ","code_information":[{"code":"11983","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9358.040,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7338.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9294.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":25510.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10840.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9756.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10840.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":9358.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9545.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10840.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":29551.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":13101.260,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":12050.310,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9545.200,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9358.040,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9732.360,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9152.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":9358.040,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7552.320,"methodology":"fee schedule"}]}]},{"description":"Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach ","code_information":[{"code":"499","type":"RC"},{"code":"50525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (prostate), augmentative algorithmic analysis of digitized whole-slide imaging of histologic features for microsatellite instability (MSI) status, formalin-fixed paraffin-embedded (FFPE) tiss ","code_information":[{"code":"0512U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1161.780,"maximum":2959.890,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1161.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2931.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1355.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1219.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1355.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1355.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2959.890,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage ","code_information":[{"code":"23101","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; exchange (ie, remov ","code_information":[{"code":"20697","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR MULTIPLE TRAUMA NO BRAIN OR SPINAL CORD INJU ","code_information":[{"code":"138","type":"RC"},{"code":"C1701","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":21697.580,"maximum":22131.530,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":22131.530,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":21697.580,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":21697.580,"methodology":"fee schedule"}]}]},{"description":"Unlisted diagnostic radiographic procedure ","code_information":[{"code":"352","type":"RC"},{"code":"76499","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Transection or repositioning of aberrant renal vessels (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"50100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to cod ","code_information":[{"code":"22208","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"350","type":"RC"},{"code":"75710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103989.730,"maximum":103989.730,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":103989.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":103989.730,"methodology":"fee schedule"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"350","type":"RC"},{"code":"75716","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103989.730,"maximum":103989.730,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":103989.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":103989.730,"methodology":"fee schedule"}]}]},{"description":"STROKE; M > 38.85 & M < 44.45 ","code_information":[{"code":"118","type":"RC"},{"code":"D0104","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":33707.030,"maximum":34381.170,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":34381.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":33707.030,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":33707.030,"methodology":"fee schedule"}]}]},{"description":"3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not ","code_information":[{"code":"400","type":"RC"},{"code":"76376","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":87.170,"maximum":101.640,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":87.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":100.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":101.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":91.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":101.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":101.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":100.930,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when per ","code_information":[{"code":"361","type":"RC"},{"code":"45397","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy ","code_information":[{"code":"499","type":"RC"},{"code":"50593","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Calculus; X-ray diffraction ","code_information":[{"code":"309","type":"RC"},{"code":"82370","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.600,"maximum":52.470,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.970,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.030,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lactoferrin, fecal; qualitative ","code_information":[{"code":"302","type":"RC"},{"code":"83630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.410,"maximum":82.560,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":81.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":34.020,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hepatitis C antibody; confirmatory test (eg, immunoblot) ","code_information":[{"code":"86804","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25.480,"maximum":64.920,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":26.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":29.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":64.920,"methodology":"fee schedule"}]}]},{"description":"DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles ","code_information":[{"code":"302","type":"RC"},{"code":"81234","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.370,"maximum":574.170,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":568.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":262.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":236.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":262.900,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"57180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow ","code_information":[{"code":"23935","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"400","type":"RC"},{"code":"74019","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":194.340,"maximum":3730.960,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":194.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":225.010,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application ","code_information":[{"code":"31643","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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","code_information":[{"code":"361","type":"RC"},{"code":"62305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft ","code_information":[{"code":"66185","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":6929.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery ","code_information":[{"code":"35131","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterizat ","code_information":[{"code":"361","type":"RC"},{"code":"93458","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8291.000,"maximum":15364.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8291.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":15364.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8702.100,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15364.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Patient lift, electric with seat or sling ","code_information":[{"code":"E0635","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC ","code_information":[{"code":"125","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13) ","code_information":[{"code":"309","type":"RC"},{"code":"83009","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":110.810,"maximum":282.310,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":110.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":279.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":129.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":116.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":129.260,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only ","code_information":[{"code":"0862T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PNEUMOTHORAX WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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","code_information":[{"code":"25315","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve ","code_information":[{"code":"481","type":"RC"},{"code":"93591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":22946.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, abdomen; 1 view ","code_information":[{"code":"320","type":"RC"},{"code":"74018","type":"CPT"},{"code":"80347","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":114.570,"maximum":133.580,"gross_charge":718.00,"discounted_cash":718.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":114.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":132.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":133.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":120.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":133.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":133.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":132.650,"methodology":"fee schedule"}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":45879.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13619.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10690.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14257.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39129.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16627.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":14964.890,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":16627.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":13619.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13891.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16627.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45329.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":19066.680,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18483.890,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":39895.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":45879.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":13891.440,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":13619.060,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":14163.820,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13319.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":13619.060,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11001.920,"methodology":"fee schedule"}]}]},{"description":"Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open ","code_information":[{"code":"490","type":"RC"},{"code":"49020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Iron binding capacity ","code_information":[{"code":"304","type":"RC"},{"code":"83550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.380,"maximum":36.630,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":15.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":16.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.630,"methodology":"fee schedule"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC ","code_information":[{"code":"073","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"17261","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dermabrasion; regional, other than face ","code_information":[{"code":"15782","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibia ","code_information":[{"code":"340","type":"RC"},{"code":"93923","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5076.670,"maximum":5076.670,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5076.670,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5076.670,"methodology":"fee schedule"}]}]},{"description":"Adenoidectomy, primary; age 12 or over ","code_information":[{"code":"42831","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence ","code_information":[{"code":"309","type":"RC"},{"code":"81364","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":533.930,"maximum":1360.310,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":533.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1347.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":622.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":560.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":622.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":622.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1360.310,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas ","code_information":[{"code":"369","type":"RC"},{"code":"58545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"116","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1222.840,"maximum":1247.300,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1222.840,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1247.300,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Angiography, spinal, selective, radiological supervision and interpretation ","code_information":[{"code":"330","type":"RC"},{"code":"75705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179418.410,"maximum":179418.410,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":179418.410,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":179418.410,"methodology":"fee schedule"}]}]},{"description":"Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary proce ","code_information":[{"code":"33257","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, osseous survey; limited (eg, for metastases) ","code_information":[{"code":"324","type":"RC"},{"code":"77074","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":348.590,"maximum":3730.960,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":348.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":403.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":406.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":365.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":406.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":406.450,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ORTHOPEDIC; M < 24.15 ","code_information":[{"code":"158","type":"RC"},{"code":"A0904","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":30470.050,"maximum":31079.450,"payers_information":[{"payer_name":"Evernorth Behavioral 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views ","code_information":[{"code":"619","type":"RC"},{"code":"72083","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Acylcarnitines; quantitative, each specimen 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procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon ","code_information":[{"code":"26350","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, internal mammary, radiological supervision and interpretation ","code_information":[{"code":"359","type":"RC"},{"code":"75756","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103989.730,"maximum":103989.730,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":103989.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":103989.730,"methodology":"fee schedule"}]}]},{"description":"Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); without optic nerve decompression ","code_information":[{"code":"369","type":"RC"},{"code":"61563","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment ","code_information":[{"code":"L2116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":977.390,"maximum":1796.380,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1007.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":1007.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1027.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":1410.670,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1796.380,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1027.770,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1027.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1007.620,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":977.390,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1047.920,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1007.620,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1027.770,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1007.620,"methodology":"fee schedule"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"200","type":"RC"},{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL  IPF","code_information":[{"code":"206","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1209.000,"maximum":1209.000,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1209.000,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"SKIN ULCERS WITHOUT CC/MCC ","code_information":[{"code":"594","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6119.810,"maximum":29291.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8293.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":6119.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8055.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22107.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9394.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8454.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9394.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":8293.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":8459.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9394.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":25610.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":11611.020,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":10443.120,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":8459.460,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8293.590,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":8625.330,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8111.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8293.590,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":6298.050,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"168","type":"MS-DRG"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy ","code_information":[{"code":"21743","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy ","code_information":[{"code":"61530","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, sella turcica ","code_information":[{"code":"330","type":"RC"},{"code":"70240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular) ","code_information":[{"code":"27087","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Exploration, repair, and presacral drainage for rectal injury; ","code_information":[{"code":"361","type":"RC"},{"code":"45562","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dilation and catheterization of salivary duct, with or without injection ","code_information":[{"code":"42660","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and ","code_information":[{"code":"361","type":"RC"},{"code":"62369","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, extensor, hand or finger, open, each tendon ","code_information":[{"code":"26460","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, sacrum and coccyx, minimum of 2 views ","code_information":[{"code":"400","type":"RC"},{"code":"72220","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":129.220,"maximum":150.660,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":129.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":149.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":150.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":135.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":150.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":150.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":149.610,"methodology":"fee schedule"}]}]},{"description":"Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC ","code_information":[{"code":"479","type":"MS-DRG"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence ","code_information":[{"code":"306","type":"RC"},{"code":"81249","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":987.000,"maximum":2514.600,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":987.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2490.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1151.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1036.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1151.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1151.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2514.600,"methodology":"fee schedule"}]}]},{"description":"Gastrocnemius recession (eg, Strayer procedure) ","code_information":[{"code":"27687","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch ","code_information":[{"code":"33641","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection procedure for Peyronie disease; ","code_information":[{"code":"369","type":"RC"},{"code":"54200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombo ","code_information":[{"code":"360","type":"RC"},{"code":"37184","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision external ear; complete amputation ","code_information":[{"code":"69120","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":6929.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Morphometric analysis; nerve ","code_information":[{"code":"310","type":"RC"},{"code":"88356","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.860,"maximum":208.540,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":206.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":95.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":85.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":95.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":95.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":208.540,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy ","code_information":[{"code":"481","type":"RC"},{"code":"64763","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each ","code_information":[{"code":"28455","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space ","code_information":[{"code":"490","type":"RC"},{"code":"63173","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COMT (catechol-O-methyltransferase) (eg, drug metabolism) gene analysis, c.472G>A (rs4680) variant 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for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nephrology (chronic kidney disease), nuclear magnetic resonance spectroscopy measurement of myo-inositol, valine, and creatinine, algorithmically combined with cystatin C and demographic data to deter 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC ","code_information":[{"code":"360","type":"RC"},{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcript ","code_information":[{"code":"302","type":"RC"},{"code":"87506","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":432.620,"maximum":1102.190,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":432.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1091.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":504.680,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"330","type":"RC"},{"code":"74220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6295.280,"maximum":6295.280,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":6295.280,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6295.280,"methodology":"fee schedule"}]}]},{"description":"Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus) 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_percentage":23.40,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3850 reimbursement is 23.4% of aggregated billable gross charges. If aggregated billable gross charges are less than $3850 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_percentage":23.40,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3850 reimbursement is 23.4% of aggregated billable gross charges. If aggregated billable gross charges are less than $3850 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. 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","code_information":[{"code":"22857","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, foot; 2 views ","code_information":[{"code":"341","type":"RC"},{"code":"73620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee 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(in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Antibody; encephalitis, Eastern equine ","code_information":[{"code":"309","type":"RC"},{"code":"86652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.700,"maximum":55.280,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":22.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":25.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.310,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic ","code_information":[{"code":"360","type":"RC"},{"code":"61548","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Aldosterone suppression evaluation panel (eg, saline infusion) This panel must include the following: Aldosterone (82088 x 2) Renin (84244 x 2) ","code_information":[{"code":"80408","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":206.450,"maximum":525.970,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":206.450,"methodology":"fee 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logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision or removal of neurostimulator electrode array, peripheral nerve, with integrated neurostimulator ","code_information":[{"code":"481","type":"RC"},{"code":"64598","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistoche ","code_information":[{"code":"312","type":"RC"},{"code":"88313","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.670,"maximum":141.820,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":140.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":58.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":64.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":141.820,"methodology":"fee schedule"}]}]},{"description":"Capsulectomy or capsulotomy; metacarpophalangeal 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for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of distal femoral epiphyseal separation; without manipulation ","code_information":[{"code":"27516","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES ","code_information":[{"code":"278","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closure of urethrovaginal fistula; ","code_information":[{"code":"57310","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereotactic stimulation of spinal cord, percutaneous, separate 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC ","code_information":[{"code":"058","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"MISCELLANEOUS; M=12-32 AND A tm81 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schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":22.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":24.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.940,"methodology":"fee schedule"}]}]},{"description":"Insertion of a temporary prostatic urethral stent, including urethral measurement ","code_information":[{"code":"361","type":"RC"},{"code":"53855","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC ","code_information":[{"code":"430","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Beta-amyloid; 1-40 (Abeta 40) ","code_information":[{"code":"309","type":"RC"},{"code":"82233","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":212.070,"maximum":540.300,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":212.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":535.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":247.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":222.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":247.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":247.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":540.300,"methodology":"fee schedule"}]}]},{"description":"Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcutaneous ","code_information":[{"code":"0818T","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29626.000,"maximum":35081.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter therapy, embolization, any method, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75894","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1032.420,"maximum":1203.750,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1032.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1195.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1203.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1083.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1203.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1203.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1195.320,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach ","code_information":[{"code":"43101","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pregnenolone ","code_information":[{"code":"306","type":"RC"},{"code":"84140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.000,"maximum":86.630,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":85.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":39.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":35.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":39.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":39.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":86.630,"methodology":"fee schedule"}]}]},{"description":"Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) ","code_information":[{"code":"30468","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ORTHOPEDIC; M < 24.15 ","code_information":[{"code":"138","type":"RC"},{"code":"C0904","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":35357.710,"maximum":36064.870,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":36064.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":35357.710,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":35357.710,"methodology":"fee schedule"}]}]},{"description":"Sesamoidectomy, first toe (separate procedure) ","code_information":[{"code":"28315","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutatio ","code_information":[{"code":"0244U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5757.500,"maximum":14668.500,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5757.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14528.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6716.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":6044.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":6716.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6716.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14668.500,"methodology":"fee schedule"}]}]},{"description":"Biliary endoscopy, percutaneous 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Concentration (any type), for infectious agents ","code_information":[{"code":"307","type":"RC"},{"code":"87015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.990,"maximum":28.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":27.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.820,"methodology":"fee 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","code_information":[{"code":"359","type":"RC"},{"code":"76886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance ","code_information":[{"code":"62329","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, internal mammary, radiological supervision and interpretation ","code_information":[{"code":"352","type":"RC"},{"code":"75756","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103989.730,"maximum":103989.730,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":103989.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":103989.730,"methodology":"fee schedule"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; simple ","code_information":[{"code":"323","type":"RC"},{"code":"77280","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1270.870,"maximum":1481.770,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1270.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1471.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1481.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1333.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1481.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1481.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1471.380,"methodology":"fee schedule"}]}]},{"description":"Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less ","code_information":[{"code":"11920","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Periodontal mucosal grafting ","code_information":[{"code":"41870","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH CC ","code_information":[{"code":"194","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Angiography, extremity, unilateral, radiological supervision and interpretation 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroplasty with prosthetic replacement; distal ulna ","code_information":[{"code":"25442","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FXN (frataxin), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem requests (STR) expansions, mobile element insertions, and variants ","code_information":[{"code":"0233U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":452.100,"maximum":1151.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.100,"methodology":"fee 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bilateral; including posteroanterior chest, minimum of 4 views ","code_information":[{"code":"324","type":"RC"},{"code":"71111","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":277.100,"maximum":3730.960,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":277.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":320.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":323.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":290.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":323.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":323.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":320.820,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Collection of venous blood by venipuncture ","code_information":[{"code":"301","type":"RC"},{"code":"36415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.940,"maximum":12.570,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12.570,"methodology":"fee schedule"}]}]},{"description":"Urinary bladder residual study (List separately in addition to code for primary procedure) ","code_information":[{"code":"349","type":"RC"},{"code":"78730","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":357.540,"maximum":416.870,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":357.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":413.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":416.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":375.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":416.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":416.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":413.950,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, temporomandibular joint, open and closed mouth; unilateral ","code_information":[{"code":"324","type":"RC"},{"code":"70328","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":138.320,"maximum":161.270,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":138.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":160.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":161.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":145.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":161.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":161.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":160.140,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) ","code_information":[{"code":"320","type":"RC"},{"code":"70336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1400.290,"maximum":1632.670,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1400.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1621.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1632.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1469.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1632.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1632.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1621.230,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, extensor, hand or finger, open, each tendon ","code_information":[{"code":"26460","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Bypass graft, with other than vein; ilio-mesenteric ","code_information":[{"code":"35633","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, pelvic (nonobstetric), real time with image documentation; complete ","code_information":[{"code":"409","type":"RC"},{"code":"76856","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component ","code_information":[{"code":"27487","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":53020.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":30033.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":34.17,"standard_charge_algorithm":"Reimbursement will be 34.17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":43.07,"standard_charge_algorithm":"Reimbursement will be 43.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":28.22,"standard_charge_algorithm":"Reimbursement will be 28.22% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":43.07,"standard_charge_algorithm":"Reimbursement will be 43.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":43.07,"standard_charge_algorithm":"Reimbursement will be 43.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Haptoglobin; phenotypes ","code_information":[{"code":"309","type":"RC"},{"code":"83012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.230,"maximum":112.700,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":111.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":51.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":46.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":51.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":51.600,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous vertebral augmentations, first lumbar and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) us 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) ","code_information":[{"code":"360","type":"RC"},{"code":"58180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (pild) or placebo-control, performed in an approved coverage with evidence development (ced) clinical trial ","code_information":[{"code":"761","type":"RC"},{"code":"G0276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC ","code_information":[{"code":"075","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard 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","code_information":[{"code":"369","type":"RC"},{"code":"59871","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application ","code_information":[{"code":"55920","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OSTEOARTHRITIS; M < 30.75 ","code_information":[{"code":"148","type":"RC"},{"code":"C1203","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":34359.000,"maximum":35046.180,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":35046.180,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":34359.000,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":34359.000,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas ","code_information":[{"code":"28003","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, sacroiliac joints; less than 3 views ","code_information":[{"code":"321","type":"RC"},{"code":"72200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":182.010,"maximum":3730.960,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":182.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":210.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":212.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":190.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":212.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":212.210,"methodology":"fee 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination; forearm, 2 views ","code_information":[{"code":"404","type":"RC"},{"code":"73090","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; axillary-femoral-femoral ","code_information":[{"code":"35654","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnesium ","code_information":[{"code":"302","type":"RC"},{"code":"83735","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.020,"maximum":28.080,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.020,"methodology":"fee 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","code_information":[{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7054.440,"maximum":35668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9478.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7054.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9435.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":25895.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11003.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9903.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":11003.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":9478.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9668.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11003.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":29998.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":13269.940,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":12232.230,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9668.100,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9478.530,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9857.670,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9270.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"360","type":"RC"},{"code":"36593","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4667.000,"maximum":8647.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8647.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":4898.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8647.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transposition and/or reimplantation; subclavian to carotid artery ","code_information":[{"code":"35694","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass ","code_information":[{"code":"33720","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tyrosine ","code_information":[{"code":"304","type":"RC"},{"code":"84510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.490,"maximum":44.550,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":18.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":20.400,"methodology":"fee 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without contrast material ","code_information":[{"code":"409","type":"RC"},{"code":"74261","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":578.760,"maximum":674.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":578.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":670.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":674.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":607.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":674.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":674.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":670.080,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC ","code_information":[{"code":"207","type":"RC"},{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft) ","code_information":[{"code":"21408","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15238.090,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":12075.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16142.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44304.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18826.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":16944.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":18826.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":15238.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":15542.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18826.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51324.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":21333.330,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20928.410,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":15542.850,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":15238.090,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":15847.610,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14902.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":15238.090,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":12427.630,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE ","code_information":[{"code":"116","type":"RC"},{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"204","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":863.520,"maximum":863.520,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":863.520,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Special teletherapy port plan, particles, hemibody, total body ","code_information":[{"code":"350","type":"RC"},{"code":"77321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12522.190,"maximum":12522.190,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":12522.190,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":12522.190,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NEC ","code_information":[{"code":"004","type":"MS-DRG"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method ","code_information":[{"code":"62201","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only ","code_information":[{"code":"323","type":"RC"},{"code":"77431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":560.210,"maximum":653.180,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":560.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":648.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":653.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":587.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":653.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":653.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":648.600,"methodology":"fee schedule"}]}]},{"description":"Procainamide; with metabolites (eg, n-acetyl procainamide) ","code_information":[{"code":"303","type":"RC"},{"code":"80192","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.550,"maximum":70.200,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":28.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":32.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.200,"methodology":"fee schedule"}]}]},{"description":"Craniotomy for craniosynostosis; bifrontal bone flap ","code_information":[{"code":"61557","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transection or avulsion of other spinal nerve, extradural ","code_information":[{"code":"64772","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hysterosalpingography, radiological supervision and interpretation ","code_information":[{"code":"339","type":"RC"},{"code":"74740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8151.690,"maximum":8151.690,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":8151.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8151.690,"methodology":"fee schedule"}]}]},{"description":"Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method ","code_information":[{"code":"28295","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) ","code_information":[{"code":"44379","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance ","code_information":[{"code":"32557","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation arteries; ethmoidal ","code_information":[{"code":"30915","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":6929.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular ","code_information":[{"code":"33208","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS  IPF","code_information":[{"code":"136","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1408.450,"maximum":1436.620,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1408.450,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1436.620,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cm 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaginectomy, partial removal of vaginal wall; 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lymphangiography, extremity only, unilateral, radiological supervision and interpretation ","code_information":[{"code":"612","type":"RC"},{"code":"75801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20194.230,"maximum":20194.230,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":20194.230,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":20194.230,"methodology":"fee schedule"}]}]},{"description":"Pooling of platelets or other blood products ","code_information":[{"code":"307","type":"RC"},{"code":"86965","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.370,"maximum":625.130,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.370,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous vertebroplasties (bone biopsies included when performed), first cervicothoracic and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, incl ","code_information":[{"code":"360","type":"RC"},{"code":"C7504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia ","code_information":[{"code":"0747T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anoplasty, plastic operation for stricture; infant ","code_information":[{"code":"46705","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"126","type":"RC"},{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Intra-atrial pacing ","code_information":[{"code":"790","type":"RC"},{"code":"93610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29614.000,"maximum":54458.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54458.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34536.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":31082.400,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":34536.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34536.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":54458.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"158","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITH CC ","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":38669.800,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11820.500,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":9078.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12162.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":33380.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14184.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":12766.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":14184.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":11820.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12056.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14184.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38669.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":16548.700,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":15768.290,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12056.910,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11820.500,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12293.320,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11560.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11820.500,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":9342.430,"methodology":"fee schedule"}]}]},{"description":"Inj, tyenne, 1 mg ","code_information":[{"code":"784","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":4.190,"maximum":7.480,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":4.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":4.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":5.870,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":7.480,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":4.280,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":4.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":4.190,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":4.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.280,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":4.190,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; femoral-femoral ","code_information":[{"code":"35558","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcript ","code_information":[{"code":"307","type":"RC"},{"code":"87505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":211.040,"maximum":537.660,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":211.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":532.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":246.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":221.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":246.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":246.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":537.660,"methodology":"fee schedule"}]}]},{"description":"Closure salivary fistula ","code_information":[{"code":"42600","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":953.880,"maximum":972.960,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":953.880,"methodology":"fee schedule","additional_payer_notes":"Days 7. 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"}]}]},{"description":"Radiologic examination, sinuses, paranasal, less than 3 views ","code_information":[{"code":"339","type":"RC"},{"code":"70210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Eptifibatide injection ","code_information":[{"code":"9420","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3.520,"maximum":6.280,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":3.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":3.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":3.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":4.930,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":6.280,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":3.590,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":3.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":3.520,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":3.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3.590,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":3.520,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws) ","code_information":[{"code":"27756","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Glossectomy; 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LARGE bladder tumor(s) ","code_information":[{"code":"499","type":"RC"},{"code":"52240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrodesis; subtalar ","code_information":[{"code":"28725","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24489.000,"maximum":28998.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"73218","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1641.970,"maximum":1914.460,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1641.970,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1901.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1914.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1723.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1914.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1914.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1901.050,"methodology":"fee schedule"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS ","code_information":[{"code":"886","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9015.430,"maximum":9294.260,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":9015.430,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":9294.260,"methodology":"fee schedule"}]}]},{"description":"HYPERTENSION WITHOUT MCC ","code_information":[{"code":"119","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation onc ","code_information":[{"code":"614","type":"RC"},{"code":"77336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4656.030,"maximum":4656.030,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4656.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4656.030,"methodology":"fee schedule"}]}]},{"description":"Orthopantogram (eg, panoramic x-ray) ","code_information":[{"code":"329","type":"RC"},{"code":"70355","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":50.680,"maximum":59.090,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":50.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":59.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":53.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":59.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":59.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.680,"methodology":"fee schedule"}]}]},{"description":"Receptor assay; progesterone ","code_information":[{"code":"305","type":"RC"},{"code":"84234","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":106.730,"maximum":271.910,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":106.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":269.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":124.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":112.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":124.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":124.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":271.910,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; ","code_information":[{"code":"322","type":"RC"},{"code":"75557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1503.140,"maximum":1752.590,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1503.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1740.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1752.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1577.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1752.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1752.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1740.310,"methodology":"fee schedule"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair ","code_information":[{"code":"11471","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); ","code_information":[{"code":"35875","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL  IPF","code_information":[{"code":"156","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1140.570,"maximum":1163.380,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1140.570,"methodology":"fee schedule","additional_payer_notes":"Days 10+. 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":6578.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6578.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10453.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Quantitative differential pulmonary perfusion, including imaging when performed ","code_information":[{"code":"342","type":"RC"},{"code":"78597","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":172.860,"maximum":201.540,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":172.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":200.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":201.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":181.390,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":201.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":201.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.130,"methodology":"fee 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schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1257.300,"methodology":"fee schedule"}]}]},{"description":"Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach ","code_information":[{"code":"481","type":"RC"},{"code":"57285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List ","code_information":[{"code":"33369","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater ","code_information":[{"code":"22905","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Division of stricture of rectum ","code_information":[{"code":"360","type":"RC"},{"code":"45150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Adenoidectomy, secondary; age 12 or over ","code_information":[{"code":"42836","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj, artesunate, 1mg ","code_information":[{"code":"00711","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":50.270,"maximum":51.830,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":50.270,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":51.830,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, renal cyst study, translumbar, contrast visualization, 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, soft tissue neck; with contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"70491","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":654.780,"maximum":763.450,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":654.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":758.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":763.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":687.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":763.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":763.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":758.100,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; tarsal (except talus or calcaneus) ","code_information":[{"code":"28171","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coracoacromial ligament release, with or without acromioplasty ","code_information":[{"code":"23415","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, innominate, subclavian artery, by thoracic incision ","code_information":[{"code":"35022","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Prostatotomy, external drainage of prostatic abscess, any approach; complicated 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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cranial suture ","code_information":[{"code":"360","type":"RC"},{"code":"61550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, mycoplasma, any source ","code_information":[{"code":"302","type":"RC"},{"code":"87109","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.320,"maximum":64.500,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":26.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":29.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":64.500,"methodology":"fee schedule"}]}]},{"description":"Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and ","code_information":[{"code":"61645","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degre ","code_information":[{"code":"361","type":"RC"},{"code":"67113","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":47704.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":21748.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":18043.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31492.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46273.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36726.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":33053.400,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":36726.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":21748.510,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":22183.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36726.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47704.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":30447.910,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":30758.290,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":36036.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":41442.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":22183.480,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":21748.510,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":22618.450,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21270.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":21748.510,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":18569.080,"methodology":"fee schedule"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed ","code_information":[{"code":"27540","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Perfluoroalkyl substances (PFAS) (eg perfluorooctanoic acid, perflurooctaine sulfonic acid),9 PFAS compounds by LC-MS/MS,plasma or serum, quantitative ","code_information":[{"code":"0457U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":326.930,"maximum":832.920,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":326.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":824.970,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":381.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":343.240,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":381.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":381.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":832.920,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique ","code_information":[{"code":"303","type":"RC"},{"code":"87640","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.720,"maximum":147.060,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":145.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":67.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":60.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":67.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":67.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":147.060,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views ","code_information":[{"code":"324","type":"RC"},{"code":"73522","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":220.560,"maximum":257.160,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":220.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":255.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":257.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":231.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":257.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":257.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":255.360,"methodology":"fee schedule"}]}]},{"description":"MAJ MULT TRAUMA NO BRAIN OR SPINAL CORD INJURY; M ","code_information":[{"code":"B1703","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":39612.100,"maximum":40404.340,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":39612.100,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":40404.340,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy ","code_information":[{"code":"45395","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"196","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views ","code_information":[{"code":"409","type":"RC"},{"code":"73503","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":269.850,"maximum":314.630,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":269.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":312.430,"methodology":"fee 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rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"115","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure) ","code_information":[{"code":"27306","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision soft tissue lesion, external auditory canal ","code_information":[{"code":"361","type":"RC"},{"code":"69145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm ","code_information":[{"code":"11443","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure) ","code_information":[{"code":"69310","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL ","code_information":[{"code":"447","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"PENIS PROCEDURES WITH CC/MCC ","code_information":[{"code":"360","type":"RC"},{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anorectal manometry, with rectal sensation and rectal balloon expulsion test, when performed ","code_information":[{"code":"322","type":"RC"},{"code":"91125","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":746.790,"maximum":870.720,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":746.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":864.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":870.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":783.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":870.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":870.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":864.620,"methodology":"fee schedule"}]}]},{"description":"Myeloperoxidase (MPO) ","code_information":[{"code":"303","type":"RC"},{"code":"83876","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":83.660,"maximum":213.150,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":83.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":211.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":97.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":87.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":97.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":97.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":213.150,"methodology":"fee schedule"}]}]},{"description":"Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete ","code_information":[{"code":"402","type":"RC"},{"code":"76827","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":143.710,"maximum":167.560,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":143.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":166.390,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":167.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":150.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":167.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":167.560,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft ","code_information":[{"code":"27132","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28614.000,"maximum":53020.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":30033.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":34.17,"standard_charge_algorithm":"Reimbursement will be 34.17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":43.07,"standard_charge_algorithm":"Reimbursement will be 43.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":28.22,"standard_charge_algorithm":"Reimbursement will be 28.22% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":43.07,"standard_charge_algorithm":"Reimbursement will be 43.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":43.07,"standard_charge_algorithm":"Reimbursement will be 43.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Antibody; HTLV-II ","code_information":[{"code":"300","type":"RC"},{"code":"86688","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.030,"maximum":58.670,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":24.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":26.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.670,"methodology":"fee schedule"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"156","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":974.840,"maximum":994.340,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":974.840,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":994.340,"methodology":"fee schedule","additional_payer_notes":"Days 10+. 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and inte ","code_information":[{"code":"47531","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture of oocyte(s)/embryo(s), less than 4 days; ","code_information":[{"code":"304","type":"RC"},{"code":"89250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.370,"maximum":625.130,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":619.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":286.240,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":257.610,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BURNS; M > 0 ","code_information":[{"code":"C2101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":28036.600,"maximum":28597.330,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":28036.600,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":28597.330,"methodology":"fee schedule"}]}]},{"description":"Immunohistochemistry or 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"310","type":"RC"},{"code":"88350","type":"CPT"},{"code":"88498","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":133.740,"maximum":340.730,"gross_charge":336.00,"discounted_cash":336.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":133.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":337.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":156.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":140.410,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon (eg, drug-coated, drug-eluting) performed on a separate target lesion from the target lesion treated with ba ","code_information":[{"code":"0914T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"REPLACEMENT OF LOWER EXTREMITY JOINT; M > 49.55 ","code_information":[{"code":"A0801","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17254.250,"maximum":17599.330,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":17254.250,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":17599.330,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC ","code_information":[{"code":"040","type":"MS-DRG"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation, division, and stripping, short saphenous vein ","code_information":[{"code":"369","type":"RC"},{"code":"37718","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure) ","code_information":[{"code":"28250","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of sternum fracture ","code_information":[{"code":"21820","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MOUTH PROCEDURES WITH CC/MCC ","code_information":[{"code":"137","type":"MS-DRG"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"HEADACHES WITH MCC ","code_information":[{"code":"102","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR analysis of 6 single-nucleotide polymorphi 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm ","code_information":[{"code":"12037","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracostomy; with open flap drainage for empyema ","code_information":[{"code":"32036","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele ","code_information":[{"code":"499","type":"RC"},{"code":"58294","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other 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may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":16097.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20803.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57095.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24261.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":21835.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":24261.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":19239.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":19624.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24261.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":66141.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":26935.690,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":26970.430,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":19624.580,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":19239.780,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":20009.370,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18816.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":19239.780,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":16566.710,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; femoral-popliteal ","code_information":[{"code":"35556","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls ","code_information":[{"code":"369","type":"RC"},{"code":"42892","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Exploration with removal of deep foreign body, forearm or wrist ","code_information":[{"code":"25248","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":6929.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Repair of scleral staphyloma with graft ","code_information":[{"code":"490","type":"RC"},{"code":"66225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens ","code_information":[{"code":"V2109","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":58.880,"maximum":108.220,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":60.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":60.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":61.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":84.980,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":108.220,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":61.910,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":61.910,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":60.700,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":58.880,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":63.130,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":60.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":61.910,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":60.700,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or d ","code_information":[{"code":"27198","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Decompression facial nerve, intratemporal; including medial to geniculate ganglion ","code_information":[{"code":"69725","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; each additional small intestine resection and anastomosis (List separately in addition to code for primary procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"44203","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Tc99m exametazime ","code_information":[{"code":"766","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":927.710,"maximum":1653.920,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":927.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":927.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":946.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":1298.790,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1653.920,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":946.260,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":946.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":927.710,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":964.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":946.260,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":927.710,"methodology":"fee schedule"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique) ","code_information":[{"code":"369","type":"RC"},{"code":"67316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Donor hysterectomy (including cold preservation); open, from living donor ","code_information":[{"code":"0665T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Activated Protein C (APC) resistance assay ","code_information":[{"code":"85307","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25.200,"maximum":64.210,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":26.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":64.210,"methodology":"fee schedule"}]}]},{"description":"3-dimensional radiotherapy plan, including dose-volume histograms ","code_information":[{"code":"339","type":"RC"},{"code":"77295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46800.030,"maximum":46800.030,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":46800.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":46800.030,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; axillary-femoral-femoral ","code_information":[{"code":"35654","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary procedure) ","code_information":[{"code":"33519","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of penile prosthesis; non-inflatable (semi-rigid) ","code_information":[{"code":"54400","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":22946.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (inclu ","code_information":[{"code":"0515T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"322","type":"RC"},{"code":"70482","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional 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logic."}]}]},{"description":"Thoracotomy; with cyst(s) removal, includes pleural procedure when performed ","code_information":[{"code":"32140","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance imaging, breast, without contrast material; unilateral ","code_information":[{"code":"329","type":"RC"},{"code":"77046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1148.480,"maximum":1339.080,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1148.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1329.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1339.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1205.170,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Clotting; high molecular weight kininogen assay (Fitzgerald factor assay) ","code_information":[{"code":"307","type":"RC"},{"code":"85293","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.140,"maximum":79.340,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":78.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":32.690,"methodology":"fee 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","code_information":[{"code":"41870","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unexplained constitutional or other heritable disorders or syndromes, tissue-specific gene expression by whole-transcriptome and next-generation sequencing, blood, formalin-fixed paraffin-embedded (FF ","code_information":[{"code":"0266U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5264.000,"maximum":13411.200,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5264.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":13283.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6140.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5526.720,"methodology":"fee 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session ","code_information":[{"code":"481","type":"RC"},{"code":"54416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":22946.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of subcutaneous implantable defibrillator electrode ","code_information":[{"code":"33271","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":39721.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39578.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":39721.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":35748.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":39721.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":39721.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":39578.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SEIZURES WITH MCC ","code_information":[{"code":"100","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter ","code_information":[{"code":"50396","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"369","type":"RC"},{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Transcatheter superior and inferior vena cava prosthetic valve implantation (ie, caval valve implantation ºCAVI»); open femoral vein approach ","code_information":[{"code":"0806T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Amputation, thigh, through femur, any level; ","code_information":[{"code":"27590","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) ","code_information":[{"code":"31255","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Enterectomy, resection of small intestine; single resection and anastomosis ","code_information":[{"code":"44120","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected ","code_information":[{"code":"0405U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2912.440,"maximum":7420.080,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2912.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7349.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3397.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3057.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3397.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3397.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7420.080,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Respiratory motion management simulation (List separately in addition to code for primary procedure) ","code_information":[{"code":"321","type":"RC"},{"code":"77293","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":549.110,"maximum":640.230,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":549.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":635.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":640.230,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"146","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1291.080,"maximum":1316.900,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1291.080,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC ","code_information":[{"code":"128","type":"RC"},{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia ","code_information":[{"code":"31298","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITHOUT CC/MCC ","code_information":[{"code":"210","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cast supplies, hip spica (one or both legs), pediatric (0-10 years), plaster ","code_information":[{"code":"Q4027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":23.360,"maximum":42.930,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":24.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":24.080,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gliadin (deamidated) (DGP) antibody, each immunoglobulin (Ig) class ","code_information":[{"code":"305","type":"RC"},{"code":"86258","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.970,"maximum":48.320,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.970,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":19.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":22.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.130,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator ","code_information":[{"code":"31527","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, skull; less than 4 views ","code_information":[{"code":"329","type":"RC"},{"code":"70250","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":45.390,"maximum":52.920,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":45.390,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":52.920,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":47.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":52.920,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of intra-aortic balloon assist device, percutaneous ","code_information":[{"code":"33967","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane ","code_information":[{"code":"33732","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and mo ","code_information":[{"code":"400","type":"RC"},{"code":"75574","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":577.890,"maximum":673.790,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":577.890,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":669.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":673.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":606.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":673.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":673.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":669.070,"methodology":"fee schedule"}]}]},{"description":"Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and ","code_information":[{"code":"351","type":"RC"},{"code":"77300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4656.030,"maximum":4656.030,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4656.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4656.030,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EMBOLISM WITHOUT MCC ","code_information":[{"code":"130","type":"RC"},{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft ","code_information":[{"code":"35876","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation ","code_information":[{"code":"402","type":"RC"},{"code":"76519","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":215.060,"maximum":250.750,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":215.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":248.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":225.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":250.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":248.990,"methodology":"fee schedule"}]}]},{"description":"Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array ","code_information":[{"code":"64584","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele ","code_information":[{"code":"58263","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29626.000,"maximum":35081.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"128","type":"RC"},{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Application of multi-layer compression system; leg (below knee), including ankle and foot ","code_information":[{"code":"29581","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies ","code_information":[{"code":"44111","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Muscle transfer, any type, shoulder or upper arm; single ","code_information":[{"code":"23395","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach ","code_information":[{"code":"63303","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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","code_information":[{"code":"323","type":"RC"},{"code":"70332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":429.910,"maximum":8151.690,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":429.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":497.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":501.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":451.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":501.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":501.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":497.740,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision mastoidectomy; resulting in complete mastoidectomy ","code_information":[{"code":"481","type":"RC"},{"code":"69601","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens ","code_information":[{"code":"V2308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":120.180,"maximum":220.890,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":123.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":123.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":126.380,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":173.460,"methodology":"fee schedule"},{"payer_name":"Centene 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"361","type":"RC"},{"code":"58291","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal ","code_information":[{"code":"369","type":"RC"},{"code":"43845","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, elastography; each additional target lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"409","type":"RC"},{"code":"76983","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recor ","code_information":[{"code":"361","type":"RC"},{"code":"93621","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29614.000,"maximum":54458.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54458.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34536.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":31082.400,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":34536.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34536.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":54458.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect ","code_information":[{"code":"29891","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"124","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1113.660,"maximum":1135.930,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1113.660,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1135.930,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1113.660,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Heterophile antibodies; screening ","code_information":[{"code":"309","type":"RC"},{"code":"86308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.520,"maximum":21.710,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.940,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21.710,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, complete acute abdomen series, including 2 or more views of the abdomen (eg, supine, erect, decubitus), and a single view chest ","code_information":[{"code":"409","type":"RC"},{"code":"74022","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":78.440,"maximum":91.450,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":78.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":90.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":91.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":82.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":91.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":91.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":90.810,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft) ","code_information":[{"code":"21366","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of foreign body, upper arm or elbow area; subcutaneous ","code_information":[{"code":"24200","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case 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adjusted for multiple procedure logic."}]}]},{"description":"New Technology - Level 45 ","code_information":[{"code":"01582","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":65880.190,"maximum":67917.720,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":65880.190,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":67917.720,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, chest; single view ","code_information":[{"code":"611","type":"RC"},{"code":"71045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RED BLOOD CELL DISORDERS WITHOUT MCC ","code_information":[{"code":"116","type":"RC"},{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per 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PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS  IPF","code_information":[{"code":"144","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1257.550,"maximum":1282.700,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1257.550,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1282.700,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1257.550,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1298.490,"maximum":1324.460,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1298.490,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1324.460,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1298.490,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cm ","code_information":[{"code":"27049","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor ","code_information":[{"code":"499","type":"RC"},{"code":"52355","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), in ","code_information":[{"code":"31647","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) ","code_information":[{"code":"21348","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj., evomela, 1 mg ","code_information":[{"code":"09375","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":18.070,"maximum":18.630,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":18.070,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":18.630,"methodology":"fee schedule"}]}]},{"description":"Inj, aponvie, 1 mg ","code_information":[{"code":"9107","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.960,"maximum":3.490,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":1.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":2.740,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":3.490,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2.000,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1.960,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2.000,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1.960,"methodology":"fee schedule"}]}]},{"description":"Rare DS Whl Gen & Mitochdrl DNA Seq Alys Proband ","code_information":[{"code":"0212U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9006.700,"maximum":22946.560,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9006.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22727.560,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10506.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9456.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10506.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10506.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.560,"methodology":"fee schedule"}]}]},{"description":"Trabecular bone score (TBS), structural condition of the bone microarchitecture; technical calculation only ","code_information":[{"code":"612","type":"RC"},{"code":"77091","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC ","code_information":[{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":29291.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8950.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7138.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8819.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24206.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10286.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9257.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10286.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":8950.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9129.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10286.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28042.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":12530.410,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":11434.660,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9129.300,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8950.290,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9308.310,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8753.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8950.290,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7346.730,"methodology":"fee schedule"}]}]},{"description":"Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon ","code_information":[{"code":"26410","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"125","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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diem"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Urography (pyelography), intravenous, with or without KUB, with or without tomography ","code_information":[{"code":"322","type":"RC"},{"code":"74400","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":596.340,"maximum":695.310,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":596.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":690.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":695.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":625.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":695.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":695.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":690.440,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach ","code_information":[{"code":"490","type":"RC"},{"code":"63307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"490","type":"RC"},{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Radiologic examination, facial bones; less than 3 views ","code_information":[{"code":"350","type":"RC"},{"code":"70140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with biopsy, single or multiple ","code_information":[{"code":"45331","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view ","code_information":[{"code":"409","type":"RC"},{"code":"72081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":237.420,"maximum":3032.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":237.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":274.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":276.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":249.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":276.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":276.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":274.880,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Calcium; ionized ","code_information":[{"code":"82330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.180,"maximum":300.530,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":12.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":19.150,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":24.390,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":300.530,"methodology":"fee 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CCN","plan_name":"FED","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":12.420,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC ","code_information":[{"code":"111","type":"RC"},{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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","code_information":[{"code":"490","type":"RC"},{"code":"55881","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"169","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Arthroplasty, temporomandibular joint, with prosthetic joint 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rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroplasty, ankle; with implant (total ankle) ","code_information":[{"code":"27702","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":53020.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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","code_information":[{"code":"22554","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26550.000,"maximum":36736.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26550.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36736.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":27866.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":30963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36736.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"154","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) ","code_information":[{"code":"21180","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Allergen specific IgG quantitative or semiquantitative, each allergen 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. 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","code_information":[{"code":"25120","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MISCELLANEOUS; M < 27.85 ","code_information":[{"code":"138","type":"RC"},{"code":"B2004","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":43874.790,"maximum":44752.290,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":44752.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":43874.790,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":43874.790,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement) ","code_information":[{"code":"26542","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique ","code_information":[{"code":"300","type":"RC"},{"code":"87480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.980,"maximum":84.030,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.980,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":34.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":38.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":84.030,"methodology":"fee schedule"}]}]},{"description":"Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), ","code_information":[{"code":"34706","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach ","code_information":[{"code":"33363","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation arteries; 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cholecystoenterostomy ","code_information":[{"code":"47570","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SPLENIC PROCEDURES WITH MCC ","code_information":[{"code":"790","type":"RC"},{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; 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","code_information":[{"code":"28208","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation ","code_information":[{"code":"611","type":"RC"},{"code":"76080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17563.220,"maximum":17563.220,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":17563.220,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17563.220,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; methemoglobin, quantitative ","code_information":[{"code":"304","type":"RC"},{"code":"83050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.490,"maximum":34.370,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":34.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":15.740,"methodology":"fee 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portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":663.930,"maximum":774.120,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":663.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":768.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":774.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":696.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":774.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":774.120,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, internal auditory meati, complete ","code_information":[{"code":"333","type":"RC"},{"code":"70134","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17563.220,"maximum":17563.220,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":17563.220,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17563.220,"methodology":"fee schedule"}]}]},{"description":"Interrogation device evaluation (in person), carotid sinus baroreflex activation therapy (BAT) modulation system including telemetric iterative communication with the implantable device to monitor dev 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colectomy, partial; with skin level cecostomy or colostomy ","code_information":[{"code":"360","type":"RC"},{"code":"44141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL  IPF","code_information":[{"code":"116","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1277.430,"maximum":1302.980,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1277.430,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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tibial or peroneal artery, initial vessel ","code_information":[{"code":"35305","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urography (pyelography), intravenous, with or without KUB, with or without tomography ","code_information":[{"code":"323","type":"RC"},{"code":"74400","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":118.480,"maximum":138.140,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":118.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":137.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":138.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":124.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":138.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":138.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":137.170,"methodology":"fee schedule"}]}]},{"description":"Partial Hospitalization ( ","code_information":[{"code":"05853","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":129.470,"maximum":133.470,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":129.470,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":133.470,"methodology":"fee schedule"}]}]},{"description":"Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment ","code_information":[{"code":"L3982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":473.870,"maximum":870.950,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":488.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":488.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":498.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":683.940,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":870.950,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":498.300,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":498.300,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":488.530,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":473.870,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":508.070,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":488.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":498.300,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":488.530,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH PTCA WITH MCC ","code_information":[{"code":"231","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":59558.890,"maximum":61400.920,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":59558.890,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":61400.920,"methodology":"fee schedule"}]}]},{"description":"Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; requiring revision of gastrostomy tract ","code_information":[{"code":"43763","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique ","code_information":[{"code":"46612","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ophthalmic ultrasonic foreign body localization ","code_information":[{"code":"349","type":"RC"},{"code":"76529","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) ","code_information":[{"code":"402","type":"RC"},{"code":"77334","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12522.190,"maximum":12522.190,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":12522.190,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":12522.190,"methodology":"fee schedule"}]}]},{"description":"Complement; total hemolytic (CH50) ","code_information":[{"code":"86162","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":33.430,"maximum":85.160,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":33.430,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":84.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":38.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":85.160,"methodology":"fee schedule"}]}]},{"description":"Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral ","code_information":[{"code":"360","type":"RC"},{"code":"62304","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT C ","code_information":[{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5066.900,"maximum":29291.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":6960.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":5066.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6502.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17845.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7583.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":6825.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":7583.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":6960.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":7099.430,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7583.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20673.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":9744.310,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":8429.920,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":7099.430,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":6960.220,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":7238.630,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6807.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC ","code_information":[{"code":"190","type":"MS-DRG"},{"code":"207","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging ","code_information":[{"code":"322","type":"RC"},{"code":"75563","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of single external papilla or tag, anus ","code_information":[{"code":"361","type":"RC"},{"code":"46220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH CC ","code_information":[{"code":"167","type":"RC"},{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious disease (Aspergillus species), real-time PCR for detection of DNA from 4 species (A. fumigatus, A. terreus, A. niger, and A. flavus), blood, lavage fluid, or tissue, qualitative reporting o 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","code_information":[{"code":"016","type":"MS-DRG"},{"code":"151","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone ","code_information":[{"code":"26615","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, adrenal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75733","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":313.590,"maximum":365.630,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":313.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":363.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":365.630,"methodology":"fee 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Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each ","code_information":[{"code":"303","type":"RC"},{"code":"82787","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.190,"maximum":33.610,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":33.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":15.390,"methodology":"fee 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portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":458.030,"maximum":534.040,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":458.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":530.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":534.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":480.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":534.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":534.040,"methodology":"fee 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","code_information":[{"code":"369","type":"RC"},{"code":"41018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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","code_information":[{"code":"54385","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colonoscopy through stoma; with transendoscopic balloon dilation ","code_information":[{"code":"361","type":"RC"},{"code":"44405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation ","code_information":[{"code":"359","type":"RC"},{"code":"76519","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; splenorenal ","code_information":[{"code":"35536","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy ","code_information":[{"code":"19302","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; subclavian-subclavian ","code_information":[{"code":"35511","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services ","code_information":[{"code":"352","type":"RC"},{"code":"77399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4656.030,"maximum":4656.030,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4656.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4656.030,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"322","type":"RC"},{"code":"74019","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":194.340,"maximum":3730.960,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":194.340,"methodology":"fee 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","code_information":[{"code":"738","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator ","code_information":[{"code":"481","type":"RC"},{"code":"64570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple 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"}]}]},{"description":"Organic acid, single, quantitative ","code_information":[{"code":"305","type":"RC"},{"code":"83921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.890,"maximum":88.890,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.890,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":88.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":36.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":40.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":88.890,"methodology":"fee schedule"}]}]},{"description":"Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session from insertion ","code_information":[{"code":"33997","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"196","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Radiologic examination, teeth; complete, full mouth ","code_information":[{"code":"619","type":"RC"},{"code":"70320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8151.690,"maximum":8151.690,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":8151.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8151.690,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC ","code_information":[{"code":"120","type":"RC"},{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ","code_information":[{"code":"323","type":"RC"},{"code":"75573","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1042.910,"maximum":1215.980,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1042.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1207.460,"methodology":"fee 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, secondary repair) ","code_information":[{"code":"499","type":"RC"},{"code":"51841","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MISCELLANEOUS; M=12-32 AND A tm81 ","code_information":[{"code":"A2005","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":31354.560,"maximum":31981.650,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":31354.560,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":31981.650,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve ","code_information":[{"code":"499","type":"RC"},{"code":"64435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, spinal, selective, radiological supervision and interpretation ","code_information":[{"code":"333","type":"RC"},{"code":"75705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179418.410,"maximum":179418.410,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":179418.410,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":179418.410,"methodology":"fee schedule"}]}]},{"description":"Complex cystometrogram (ie, calibrated electronic equipment); ","code_information":[{"code":"499","type":"RC"},{"code":"51726","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy ","code_information":[{"code":"360","type":"RC"},{"code":"61322","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined ","code_information":[{"code":"L6722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2363.710,"maximum":4344.340,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2436.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":2436.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2485.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":3411.530,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":4344.340,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2485.550,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2485.550,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2436.810,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2363.710,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2534.280,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2436.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2485.550,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2436.810,"methodology":"fee schedule"}]}]},{"description":"Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs ","code_information":[{"code":"15572","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) ","code_information":[{"code":"20650","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon 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dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Aortography, abdominal, by serialography, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":661.830,"maximum":103989.730,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":661.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":766.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":771.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":694.490,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":771.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":771.660,"methodology":"fee 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schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1820.430,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":2022.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2022.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2008.520,"methodology":"fee schedule"}]}]},{"description":"Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed ","code_information":[{"code":"23630","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Level 5 Gynecologic Proce ","code_information":[{"code":"05415","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":5179.970,"maximum":5340.170,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5179.970,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision inferior turbinate, partial or complete, any method ","code_information":[{"code":"30130","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex ","code_information":[{"code":"25107","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy ","code_information":[{"code":"43124","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical ","code_information":[{"code":"361","type":"RC"},{"code":"63300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requir ","code_information":[{"code":"66987","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, denileukin diftitox-cxdl, 1 mcg ","code_information":[{"code":"J9161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15.190,"maximum":32.690,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":17.140,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":15.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.050,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":32.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":32.690,"methodology":"fee schedule"}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck ","code_information":[{"code":"24136","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine, lumbosacral; 2 or 3 views ","code_information":[{"code":"330","type":"RC"},{"code":"72100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":109157.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":27153.780,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":22253.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":93600.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":98241.300,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":27153.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":27696.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":109157.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":38015.290,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":38919.540,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":73272.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":73272.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":27696.860,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":27153.780,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":28239.930,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":26556.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":27153.780,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":22901.870,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":542.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1185.550,"methodology":"fee schedule"}]}]},{"description":"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm ","code_information":[{"code":"12017","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, posterior chamber of eye, medication ","code_information":[{"code":"0699T","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29626.000,"maximum":35081.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist ","code_information":[{"code":"L5855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":366.750,"maximum":674.060,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":378.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":378.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":385.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":529.330,"methodology":"fee schedule"},{"payer_name":"Centene Granite State 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schedule"}]}]},{"description":"Myelography, lumbosacral, radiological supervision and interpretation ","code_information":[{"code":"404","type":"RC"},{"code":"72265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25858.060,"maximum":25858.060,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25858.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":25858.060,"methodology":"fee schedule"}]}]},{"description":"Application of halo, including removal; femoral ","code_information":[{"code":"20663","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) ","code_information":[{"code":"319","type":"RC"},{"code":"88363","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.580,"maximum":103.390,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":102.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":47.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":42.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":47.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":47.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":103.390,"methodology":"fee schedule"}]}]},{"description":"Excision of lacrimal gland tumor; involving osteotomy ","code_information":[{"code":"361","type":"RC"},{"code":"68550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, dislocating peroneal tendons; without fibular osteotomy ","code_information":[{"code":"27675","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drainage of scrotal wall abscess ","code_information":[{"code":"499","type":"RC"},{"code":"55100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction ","code_information":[{"code":"29888","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; reducible ","code_information":[{"code":"369","type":"RC"},{"code":"49621","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COMPLEX AORTIC ARCH PROCEDURES ","code_information":[{"code":"209","type":"MS-DRG"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Ureteral reflux study (radiopharmaceutical voiding cystogram) ","code_information":[{"code":"349","type":"RC"},{"code":"78740","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1057.550,"maximum":1233.060,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1057.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1224.420,"methodology":"fee 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"66770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":34.17,"standard_charge_algorithm":"Reimbursement will be 34.17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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1 or 2 views ","code_information":[{"code":"342","type":"RC"},{"code":"73560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy ","code_information":[{"code":"43124","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"114","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":938.970,"maximum":957.750,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":938.970,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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"}]}]},{"description":"Thallium tl-201 thallous chloride, diagnostic, per millicurie ","code_information":[{"code":"A9505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":40.990,"maximum":88.240,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":51.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":46.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":40.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":51.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":51.410,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"124","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) ","code_information":[{"code":"0176U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":105.590,"maximum":269.020,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":105.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":266.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":123.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":110.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":123.180,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":123.180,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy ","code_information":[{"code":"15830","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping ","code_information":[{"code":"0264U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2078.510,"maximum":5295.450,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2078.510,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5244.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2424.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":2182.240,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":2424.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2424.710,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5295.450,"methodology":"fee schedule"}]}]},{"description":"Hyperthermia generated by intracavitary probe(s) ","code_information":[{"code":"324","type":"RC"},{"code":"77620","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":447.540,"maximum":521.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":447.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":518.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":521.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":469.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":521.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":521.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":518.150,"methodology":"fee schedule"}]}]},{"description":"Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure) ","code_information":[{"code":"61517","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH CC ","code_information":[{"code":"138","type":"RC"},{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":53883.040,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15929.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":13259.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16947.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46513.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19765.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":17788.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":19765.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":15929.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":16247.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19765.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53883.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":22300.750,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":21971.760,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":16247.690,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":15929.110,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":16566.270,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15578.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":15929.110,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13645.530,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy ","code_information":[{"code":"52224","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous vertebroplasties (bone biopsies included when performed), first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusiv 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"127","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj, tislelizumab-jsgr ","code_information":[{"code":"816","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":58.370,"maximum":104.060,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":58.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":58.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":59.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":81.720,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":104.060,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":59.540,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, trochanteric pressure ulcer, with primary suture; ","code_information":[{"code":"15950","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PNEUMOTHORAX WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid processºes»), includes internal fixation, when performed ","code_information":[{"code":"24685","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple ","code_information":[{"code":"42960","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, femur; minimum 2 views ","code_information":[{"code":"401","type":"RC"},{"code":"73552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in ad ","code_information":[{"code":"22116","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation ","code_information":[{"code":"0536U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":315.840,"maximum":804.670,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":315.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":368.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":331.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":368.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":368.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":804.670,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC ","code_information":[{"code":"098","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":67805.120,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19689.020,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":15642.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21326.510,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58531.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24872.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":22384.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":24872.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":19689.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":20082.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24872.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67805.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":27564.630,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":27648.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":20082.800,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":19689.020,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":20476.580,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19255.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":19689.020,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":16098.400,"methodology":"fee schedule"}]}]},{"description":"Transcatheter implantation of coronary sinus reduction device including vascular access and closure, right heart catheterization, venous angiography, coronary sinus angiography, imaging guidance, and ","code_information":[{"code":"0645T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Therapeutic apheresis; for platelets ","code_information":[{"code":"360","type":"RC"},{"code":"36513","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy, with biopsy(s) ","code_information":[{"code":"52204","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with other than vein; aortosubclavian, aortoinnominate, or aortocarotid ","code_information":[{"code":"35626","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"209","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulodesis, metacarpophalangeal joint; single digit ","code_information":[{"code":"26516","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KI ","code_information":[{"code":"0105U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1562.750,"maximum":3981.450,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1562.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3943.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1823.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1640.750,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1823.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1823.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3981.450,"methodology":"fee schedule"}]}]},{"description":"Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft ","code_information":[{"code":"66180","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biofeedback training by any modality ","code_information":[{"code":"90901","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":37.090,"maximum":66.130,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":37.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":37.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":37.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":51.930,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":66.130,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":37.830,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":37.830,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":37.090,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":38.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":37.830,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":37.090,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"137","type":"RC"},{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Removal of foreign body in muscle or tendon sheath; simple ","code_information":[{"code":"20520","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5019.000,"maximum":5943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of indwelling tunneled pleural catheter with cuff ","code_information":[{"code":"32552","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, small intestine ","code_information":[{"code":"44799","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis ","code_information":[{"code":"361","type":"RC"},{"code":"50715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limi 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation ","code_information":[{"code":"67039","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Secondary revision of orbitocraniofacial reconstruction ","code_information":[{"code":"21275","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance angiography, neck; without contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"70547","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1159.280,"maximum":1351.660,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1159.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1342.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1351.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1216.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1351.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1351.660,"methodology":"fee 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","code_information":[{"code":"43255","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC ","code_information":[{"code":"148","type":"RC"},{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"55200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft) ","code_information":[{"code":"23155","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"320","type":"RC"},{"code":"74170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1399.060,"maximum":1631.230,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1399.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1619.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1631.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1468.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1631.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1631.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1619.800,"methodology":"fee schedule"}]}]},{"description":"Endomyocardial biopsy ","code_information":[{"code":"481","type":"RC"},{"code":"93505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region ","code_information":[{"code":"27301","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj, Imm Glob Bivigam, 50 ","code_information":[{"code":"9130","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":79.640,"maximum":141.990,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":79.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":79.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":81.240,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":111.500,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":141.990,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":81.240,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":81.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":79.640,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":82.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":81.240,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":79.640,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, chest; 2 views ","code_information":[{"code":"615","type":"RC"},{"code":"71046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis ºFAP», attenuated FAP) gene analysis; duplication/deletion variants ","code_information":[{"code":"81203","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":178.190,"maximum":4394.340,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":200.000,"methodology":"fee schedule"},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":178.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":200.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":204.000,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":280.000,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":356.560,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4394.340,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4394.340,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":204.000,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":204.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":200.000,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":208.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":204.000,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":200.000,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":181.650,"methodology":"fee schedule"}]}]},{"description":"Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study ","code_information":[{"code":"618","type":"RC"},{"code":"93981","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; axillary-popliteal or -tibial ","code_information":[{"code":"35623","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of metatarsal fracture; without manipulation, each 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MSH6 (mutS homolog 6 ºE. coli») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants 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(nonobstetrical) ","code_information":[{"code":"499","type":"RC"},{"code":"58520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Upper extremity addition, disconnect locking wrist unit ","code_information":[{"code":"L6615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":206.290,"maximum":379.150,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":212.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":212.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":216.920,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":297.740,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":379.150,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":216.920,"methodology":"fee 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with removal of foreign body(s) ","code_information":[{"code":"43247","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":6929.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"148","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Glossectomy; 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forehead ","code_information":[{"code":"15824","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Acetylcholinesterase ","code_information":[{"code":"307","type":"RC"},{"code":"82013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.220,"maximum":51.510,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.220,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":23.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.510,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, temporomandibular joint, open and closed mouth; bilateral ","code_information":[{"code":"615","type":"RC"},{"code":"70330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral ","code_information":[{"code":"22015","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"143","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Application, cast; shoulder to hand (long arm) ","code_information":[{"code":"29065","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"23076","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral ","code_information":[{"code":"481","type":"RC"},{"code":"63283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability ºXLID») gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"81243","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":93.830,"maximum":239.050,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":93.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":236.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":109.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":98.510,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":109.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":109.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":239.050,"methodology":"fee 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","code_information":[{"code":"145","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dihydrotestosterone (DHT) 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5443.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8647.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, ankle, including exploration, drainage, or removal of foreign body ","code_information":[{"code":"27610","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5851.000,"maximum":6929.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) ","code_information":[{"code":"309","type":"RC"},{"code":"37678","type":"CDM"},{"code":"89060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.060,"maximum":30.720,"gross_charge":59.00,"discounted_cash":59.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":30.430,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":14.070,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.070,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Clotting; factor II, prothrombin, specific ","code_information":[{"code":"300","type":"RC"},{"code":"85210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.350,"maximum":54.400,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53.880,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":22.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":24.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":54.400,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of appendiceal abscess, open ","code_information":[{"code":"44900","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score ","code_information":[{"code":"0547T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination; lower extremity, infant, minimum of 2 views ","code_information":[{"code":"324","type":"RC"},{"code":"73592","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":165.660,"maximum":3032.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":165.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":193.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":173.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":193.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":193.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":191.800,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery ","code_information":[{"code":"35131","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OSTEOARTHRITIS; M=39-47 ","code_information":[{"code":"118","type":"RC"},{"code":"C1204","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":35374.320,"maximum":36081.810,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":36081.810,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":35374.320,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":35374.320,"methodology":"fee schedule"}]}]},{"description":"Gastroenterology (Barrett's esophagus), whole slide-digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX- ","code_information":[{"code":"0108U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4134.300,"maximum":10533.030,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4134.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10432.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4822.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":4340.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":4822.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4822.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10533.030,"methodology":"fee schedule"}]}]},{"description":"Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed ","code_information":[{"code":"27269","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case 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procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) stu ","code_information":[{"code":"341","type":"RC"},{"code":"74251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6295.280,"maximum":6295.280,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":6295.280,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6295.280,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC ","code_information":[{"code":"118","type":"RC"},{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Transfer of tendon to restore intrinsic function; all 4 fingers ","code_information":[{"code":"26498","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"750","type":"RC"},{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urography, retrograde, with or without KUB ","code_information":[{"code":"339","type":"RC"},{"code":"74420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12861.150,"maximum":12861.150,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":12861.150,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":12861.150,"methodology":"fee schedule"}]}]},{"description":"Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage ","code_information":[{"code":"33645","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anterior lumbar or thoracolumbar vertebral body tethering; up to 7 vertebral segments ","code_information":[{"code":"0656T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with dilation, initial ","code_information":[{"code":"31528","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"333","type":"RC"},{"code":"75820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":51937.800,"maximum":51937.800,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":51937.800,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":51937.800,"methodology":"fee schedule"}]}]},{"description":"Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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smear and/or culture ","code_information":[{"code":"65430","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":2723.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (eg, Stener lesion) ","code_information":[{"code":"29902","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1211.920,"maximum":1236.160,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1211.920,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1236.160,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1211.920,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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profiles","setting":"outpatient","minimum":1023.320,"maximum":1193.150,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1023.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1184.780,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1193.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1073.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1193.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1193.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1184.780,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) ","code_information":[{"code":"45350","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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","code_information":[{"code":"84153","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30.250,"maximum":77.070,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":76.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":31.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":35.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.290,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":77.070,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) ","code_information":[{"code":"43232","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"61535","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source ","code_information":[{"code":"490","type":"RC"},{"code":"61770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator ","code_information":[{"code":"499","type":"RC"},{"code":"64568","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":66787.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66787.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":42354.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":38118.600,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":42354.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":42354.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":66787.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Parathyroidectomy or exploration of parathyroid(s); re-exploration ","code_information":[{"code":"481","type":"RC"},{"code":"60502","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical ","code_information":[{"code":"22864","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine, cervical; 4 or 5 views ","code_information":[{"code":"619","type":"RC"},{"code":"72050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"Q4193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1560.020,"maximum":3690.370,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3690.370,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3690.370,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1560.020,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1608.270,"methodology":"fee schedule"}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC ","code_information":[{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":36834.000,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":17512.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":12675.190,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31585.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36834.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36834.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":33150.600,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":36834.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":17512.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":17862.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36834.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36834.000,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":24517.120,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":24362.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":17862.470,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":17512.230,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":18212.720,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17126.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":17512.230,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13044.370,"methodology":"fee schedule"}]}]},{"description":"Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm ","code_information":[{"code":"14021","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation; internal or common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp ","code_information":[{"code":"369","type":"RC"},{"code":"37606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia ","code_information":[{"code":"69421","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mastectomy, radical, including pectoral muscles, axillary lymph nodes ","code_information":[{"code":"19305","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Non-cardiac vascular flow imaging (ie, angiography, venography) ","code_information":[{"code":"33754","type":"CDM"},{"code":"341","type":"RC"},{"code":"78445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":905.670,"maximum":1055.970,"gross_charge":1384.00,"discounted_cash":1384.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":905.670,"methodology":"fee 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","code_information":[{"code":"26445","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chloride; urine ","code_information":[{"code":"82436","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9.460,"maximum":24.100,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9.460,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":23.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":11.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":24.100,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, direct probe technique ","code_information":[{"code":"300","type":"RC"},{"code":"87560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.890,"maximum":114.370,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.890,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":113.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":52.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":47.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":52.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":52.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":114.370,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach ","code_information":[{"code":"361","type":"RC"},{"code":"63307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CACNA1A, full gene analysis, including small sequence changes in exonic and intronic regions, deletions duplications, Short Tandem Requests (STR) gene expansions, mobile element insertions, and varian ","code_information":[{"code":"0231U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1392.110,"maximum":3546.720,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1392.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3512.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1623.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1461.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1623.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1623.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3546.720,"methodology":"fee schedule"}]}]},{"description":"Ablation of benign prostate tissue, 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnor ","code_information":[{"code":"401","type":"RC"},{"code":"76506","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, stomach ","code_information":[{"code":"43999","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj, human-lans, per i.u ","code_information":[{"code":"702","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.710,"maximum":3.040,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1.710,"methodology":"fee 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","code_information":[{"code":"24579","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, shoulder; complete, minimum of 2 views ","code_information":[{"code":"324","type":"RC"},{"code":"73030","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":145.670,"maximum":169.840,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":145.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":168.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":169.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":152.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":169.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":169.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":168.650,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, lumbosacral; minimum of 4 views ","code_information":[{"code":"350","type":"RC"},{"code":"72110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Open treatment of mandibular fracture; without interdental fixation ","code_information":[{"code":"21461","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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","code_information":[{"code":"490","type":"RC"},{"code":"63266","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; cholecystectomy with cholangiography ","code_information":[{"code":"360","type":"RC"},{"code":"47563","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) ","code_information":[{"code":"614","type":"RC"},{"code":"77423","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19983.760,"maximum":19983.760,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19983.760,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19983.760,"methodology":"fee schedule"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH CC ","code_information":[{"code":"137","type":"RC"},{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon (eg, drug-coated, 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","code_information":[{"code":"27442","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28614.000,"maximum":53020.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":30033.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) ","code_information":[{"code":"31090","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal femur, proximal tibia and fibula ","code_information":[{"code":"27479","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness) ","code_information":[{"code":"341","type":"RC"},{"code":"76514","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":871.290,"maximum":871.290,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":871.290,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":871.290,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm ","code_information":[{"code":"17276","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Special teletherapy port plan, particles, hemibody, total body ","code_information":[{"code":"324","type":"RC"},{"code":"77321","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":244.300,"maximum":284.850,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":244.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":282.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":284.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":256.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":284.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":284.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":282.850,"methodology":"fee schedule"}]}]},{"description":"Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types ","code_information":[{"code":"309","type":"RC"},{"code":"87206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.870,"maximum":22.590,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22.590,"methodology":"fee schedule"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Ethmoidectomy; extranasal, total ","code_information":[{"code":"31205","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thymectomy, partial or total; transcervical approach (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"60520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":9236.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"72142","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1475.540,"maximum":1720.410,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1475.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1708.350,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1720.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1548.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1720.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1720.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1708.350,"methodology":"fee schedule"}]}]},{"description":"Unlisted hematology and coagulation procedure ","code_information":[{"code":"85999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":777.100,"maximum":777.100,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":777.100,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":777.100,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC ","code_information":[{"code":"060","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15163.080,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":12674.470,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16055.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44064.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18724.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":16852.330,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":18724.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":15163.080,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":15466.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18724.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51046.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":21228.310,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20815.160,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":15466.340,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":15163.080,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":15769.600,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14829.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":15163.080,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13043.630,"methodology":"fee schedule"}]}]},{"description":"Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel ","code_information":[{"code":"0235T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates ","code_information":[{"code":"302","type":"RC"},{"code":"87075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.580,"maximum":39.690,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.310,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":16.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":18.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":39.690,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC ","code_information":[{"code":"212","type":"RC"},{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0290U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.200,"maximum":3185.160,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3154.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1312.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3185.160,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"304","type":"RC"},{"code":"87336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.320,"maximum":67.060,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.320,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":27.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":30.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.060,"methodology":"fee schedule"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; 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single lesion ","code_information":[{"code":"19125","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MINOR BLADDER PROCEDURES WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Computed tomography, soft tissue neck; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"70490","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":494.520,"maximum":576.590,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":494.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":572.550,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":576.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":518.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":576.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":576.590,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":572.550,"methodology":"fee schedule"}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular ","code_information":[{"code":"33207","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22781.000,"maximum":26976.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to codeºs» for other technical and ","code_information":[{"code":"310","type":"RC"},{"code":"88155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.100,"maximum":61.400,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":60.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":25.300,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":28.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.110,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.400,"methodology":"fee schedule"}]}]},{"description":"Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus ","code_information":[{"code":"47400","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use ","code_information":[{"code":"90685","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":0.010,"maximum":56.690,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":17.00,"standard_charge_algorithm":"Reimbursement will be 17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":0.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.010,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":0.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_percentage":17.00,"standard_charge_algorithm":"Reimbursement will be 17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_percentage":17.34,"standard_charge_algorithm":"Reimbursement will be 17.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_percentage":23.80,"standard_charge_algorithm":"Reimbursement will be 23.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_percentage":30.31,"standard_charge_algorithm":"Reimbursement will be 30.31% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":56.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":56.690,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_percentage":17.34,"standard_charge_algorithm":"Reimbursement will be 17.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_percentage":17.34,"standard_charge_algorithm":"Reimbursement will be 17.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_percentage":17.00,"standard_charge_algorithm":"Reimbursement will be 17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_percentage":17.68,"standard_charge_algorithm":"Reimbursement will be 17.68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_percentage":17.34,"standard_charge_algorithm":"Reimbursement will be 17.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_percentage":17.00,"standard_charge_algorithm":"Reimbursement will be 17% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter ","code_information":[{"code":"369","type":"RC"},{"code":"49436","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"110","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION LEAD ONLY ","code_information":[{"code":"0426T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":22946.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Temporomandibular joint arthrography, radiological supervision and interpretation ","code_information":[{"code":"404","type":"RC"},{"code":"70332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8151.690,"maximum":8151.690,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":8151.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8151.690,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, sella turcica ","code_information":[{"code":"322","type":"RC"},{"code":"70240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":172.700,"maximum":3032.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":172.700,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":199.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":201.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":181.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":201.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":201.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":199.950,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"829","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15659.890,"maximum":16144.220,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":15659.890,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":16144.220,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of humeral condylar fracture, medial or lateral; with manipulation ","code_information":[{"code":"24577","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug ","code_information":[{"code":"306","type":"RC"},{"code":"81536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":292.090,"maximum":744.150,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":292.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":737.050,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":340.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":306.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":340.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":340.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":744.150,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"790","type":"RC"},{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Angiography, adrenal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"75733","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103989.730,"maximum":103989.730,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":103989.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":103989.730,"methodology":"fee schedule"}]}]},{"description":"Removal and replacement of externally accessible nephroureteral catheter (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation ","code_information":[{"code":"50387","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of hyperplastic alveolar mucosa, each quadrant (specify) ","code_information":[{"code":"369","type":"RC"},{"code":"41828","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of clavicle or scapula; ","code_information":[{"code":"23140","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE LEUKEMIA WITHOUT CC/MCC 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schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1631.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1631.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1619.800,"methodology":"fee schedule"}]}]},{"description":"MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"301","type":"RC"},{"code":"81294","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":332.950,"maximum":848.260,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":332.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":840.160,"methodology":"fee 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schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":19.930,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":22.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.150,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.360,"methodology":"fee schedule"}]}]},{"description":"Cineplasty, upper extremity, complete procedure ","code_information":[{"code":"24940","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision inferior turbinate, partial or complete, any method ","code_information":[{"code":"30130","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Labyrinthectomy; transcanal ","code_information":[{"code":"490","type":"RC"},{"code":"69905","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"URETHRAL STRICTURE ","code_information":[{"code":"202","type":"RC"},{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of implant from finger or hand ","code_information":[{"code":"26320","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses ","code_information":[{"code":"0036U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7863.100,"maximum":20032.980,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7863.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19841.780,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complement; antigen, each component ","code_information":[{"code":"302","type":"RC"},{"code":"86160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.740,"maximum":50.290,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":20.730,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":23.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.290,"methodology":"fee schedule"}]}]},{"description":"Screening digital breast tomosynthesis, bilateral (List 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Level I - Surgical pathology, gross examination only ","code_information":[{"code":"312","type":"RC"},{"code":"88300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.580,"maximum":103.390,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":102.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":47.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":42.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":47.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":47.340,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":103.390,"methodology":"fee schedule"}]}]},{"description":"Destruction of lesion (except excision), dentoalveolar structures ","code_information":[{"code":"41850","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urea nitrogen; quantitative ","code_information":[{"code":"84520","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6.500,"maximum":16.550,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":6.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":7.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.550,"methodology":"fee schedule"}]}]},{"description":"Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels ","code_information":[{"code":"324","type":"RC"},{"code":"77771","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":1049.640,"maximum":1223.830,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1049.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1215.250,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1223.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1101.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1223.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1223.830,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1215.250,"methodology":"fee schedule"}]}]},{"description":"Flotufolastat f18 diag 1 ","code_information":[{"code":"09254","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":651.080,"maximum":671.220,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":651.080,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":671.220,"methodology":"fee schedule"}]}]},{"description":"RED BLOOD CELL DISORDERS WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Unlisted procedure, vestibule of mouth ","code_information":[{"code":"369","type":"RC"},{"code":"40899","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":10846.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITH CC ","code_information":[{"code":"116","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type procedure) ","code_information":[{"code":"28760","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix ","code_information":[{"code":"499","type":"RC"},{"code":"57460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"155","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) ","code_information":[{"code":"342","type":"RC"},{"code":"78434","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":150.650,"maximum":175.650,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":150.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":174.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":175.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":158.090,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":175.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":175.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":174.420,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, cervical; 6 or more views ","code_information":[{"code":"329","type":"RC"},{"code":"72052","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":264.400,"maximum":308.280,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":264.400,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":306.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":308.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":277.450,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":308.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":308.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":306.120,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"CORONARY BYPASS WITH PTCA WITHOUT MCC ","code_information":[{"code":"232","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":42833.490,"maximum":44158.240,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":42833.490,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":44158.240,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6332.000,"maximum":46171.530,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13846.480,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":11657.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14522.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39856.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16936.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":15242.890,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":16936.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":13846.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":14123.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16936.540,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46171.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":19385.070,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18827.250,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23535.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29291.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":14123.410,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":13846.480,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":14400.340,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":6332.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13541.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":13846.480,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11997.180,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus ","code_information":[{"code":"499","type":"RC"},{"code":"52320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation ","code_information":[{"code":"28636","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"189","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Radiological examination, surgical specimen ","code_information":[{"code":"322","type":"RC"},{"code":"76098","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":76.740,"maximum":89.480,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":76.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":88.850,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":89.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":80.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":89.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":89.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":88.850,"methodology":"fee schedule"}]}]},{"description":"Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up of multiloculated effusion); initial day ","code_information":[{"code":"32561","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1332.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1332.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2723.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs by quantitative reverse transcription polymerase chain reaction, urine, reported as molecular evidence of no-, low-, intermediat ","code_information":[{"code":"0343U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.200,"maximum":3185.160,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3154.760,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1312.600,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1458.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3185.160,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) ","code_information":[{"code":"29885","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC ","code_information":[{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7757.000,"maximum":147357.720,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":41173.660,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":57.80,"standard_charge_algorithm":"Reimbursement will be 57.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":36625.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":46347.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":127203.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":54053.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":48648.100,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.30,"standard_charge_algorithm":"Reimbursement will be 43.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":54053.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":41173.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":41997.130,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":54053.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":147357.720,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":57643.120,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":60087.700,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31017.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35668.000,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":41997.130,"methodology":"fee schedule"},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":32.14,"standard_charge_algorithm":"Reimbursement will be 32.14% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":26.54,"standard_charge_algorithm":"Reimbursement will be 26.54% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":40.51,"standard_charge_algorithm":"Reimbursement will be 40.51% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":41173.660,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":42820.610,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":40267.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":41173.660,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":37692.570,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (tropical fever pathogens), vectorborne and zoonotic pathogens, including 2 viruses (Chikungunya virus and Dengue virus serotypes 1, 2, 3, and 4), ","code_information":[{"code":"0595U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":432.620,"maximum":1102.190,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":432.620,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1091.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":504.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":454.210,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":504.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":504.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1102.190,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ankle; 2 views ","code_information":[{"code":"329","type":"RC"},{"code":"73600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.810,"maximum":3032.810,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":174.810,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":202.390,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":203.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":183.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":203.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":203.820,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":202.390,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure) ","code_information":[{"code":"340","type":"RC"},{"code":"78020","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":289.480,"maximum":337.530,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":289.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":335.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":337.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":303.770,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":337.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":337.530,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":335.160,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS  IPF","code_information":[{"code":"114","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1358.150,"maximum":1385.310,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1358.150,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1385.310,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1358.150,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Thyroidectomy, total or complete with parathyroid autotransplantation ","code_information":[{"code":"750","type":"RC"},{"code":"C7555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC ","code_information":[{"code":"255","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Antibody; mucormycosis ","code_information":[{"code":"302","type":"RC"},{"code":"86732","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.680,"maximum":62.860,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.680,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":25.910,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":28.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.860,"methodology":"fee schedule"}]}]},{"description":"Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace ","code_information":[{"code":"361","type":"RC"},{"code":"63075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE ","code_information":[{"code":"153","type":"RC"},{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH CC ","code_information":[{"code":"481","type":"RC"},{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator ","code_information":[{"code":"360","type":"RC"},{"code":"64583","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vitamin D; 25 hydroxy, includes fraction(s), if performed ","code_information":[{"code":"82306","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":48.690,"maximum":124.050,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":48.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":122.870,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":56.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":51.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":56.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":56.800,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":124.050,"methodology":"fee schedule"}]}]},{"description":"STROKE; 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each ","code_information":[{"code":"A7522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":62.430,"maximum":114.740,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":64.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":64.360,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":65.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":90.100,"methodology":"fee 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical ","code_information":[{"code":"22861","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC; M < 31.15 ","code_information":[{"code":"118","type":"RC"},{"code":"C1404","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":35907.940,"maximum":36626.100,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":36626.100,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":35907.940,"methodology":"fee schedule"},{"payer_name":"United VA 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","code_information":[{"code":"146","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tiss 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","code_information":[{"code":"21445","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Keratoplasty (corneal transplant); penetrating (in pseudophakia) ","code_information":[{"code":"369","type":"RC"},{"code":"65755","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) ","code_information":[{"code":"32674","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Penile venous occlusive procedure ","code_information":[{"code":"37790","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6298.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1397.700,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); REDUCIBLE (SEPARATE PROCEDURE) 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection of elbow joint (arthrectomy) ","code_information":[{"code":"24155","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) ","code_information":[{"code":"409","type":"RC"},{"code":"77086","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":145.670,"maximum":169.840,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":145.670,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":168.650,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":169.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":152.860,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":169.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":169.840,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":168.650,"methodology":"fee schedule"}]}]},{"description":"Factor xiii recomb a-subu ","code_information":[{"code":"01746","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":18.010,"maximum":18.560,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":18.010,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":18.560,"methodology":"fee schedule"}]}]},{"description":"Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach ","code_information":[{"code":"66183","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":29626.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":35081.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED ","code_information":[{"code":"49566","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.000,"maximum":18158.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17633.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, adrenal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75733","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":628.260,"maximum":732.520,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":628.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":727.390,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":732.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":659.270,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":732.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":732.520,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":727.390,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, elbow; 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"73070","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":116.420,"maximum":135.740,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":116.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.790,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":135.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":122.170,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":135.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":135.740,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":134.790,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1168.640,"maximum":1192.010,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1168.640,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1192.010,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1168.640,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Unlisted procedure, therapeutic radiology clinical treatment planning ","code_information":[{"code":"329","type":"RC"},{"code":"77299","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4656.030,"maximum":4656.030,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4656.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4656.030,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, cervical; 2 or 3 views ","code_information":[{"code":"612","type":"RC"},{"code":"72040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood 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schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3181.180,"methodology":"fee schedule"}]}]},{"description":"Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus i ","code_information":[{"code":"306","type":"RC"},{"code":"80069","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.280,"maximum":36.380,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14.280,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.030,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":14.990,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":16.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16.660,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.380,"methodology":"fee schedule"}]}]},{"description":"Sympathectomy; radial artery ","code_information":[{"code":"361","type":"RC"},{"code":"64821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"53460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":5943.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC ","code_information":[{"code":"204","type":"RC"},{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, any combination of intracoronary 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":14556.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14556.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22953.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of lung, other than pneumonectomy; single lobe (lobectomy) ","code_information":[{"code":"32480","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":19985.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"AMPUTATION, NON-LOWER EXTREMITY; M > 36.35 ","code_information":[{"code":"B1101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":28080.200,"maximum":28641.800,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":28080.200,"methodology":"fee 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further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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","code_information":[{"code":"206","type":"RC"},{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal ","code_information":[{"code":"499","type":"RC"},{"code":"66985","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":22392.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18910.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22392.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (ovarian), DNA, whole-genome sequencing with 5-hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not detected ","code_information":[{"code":"0507U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1908.200,"maximum":4861.560,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1908.200,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4815.160,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2226.040,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":2003.440,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":2226.040,"methodology":"fee 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Correction, hallux valgus with 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of perinephric cyst ","code_information":[{"code":"360","type":"RC"},{"code":"50290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case 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logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone strength and fracture risk using finite element analysis of functional data and bone-mineral density utilizing data from a computed tomography 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"74328","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venograp 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12052.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sialography, radiological supervision and interpretation ","code_information":[{"code":"615","type":"RC"},{"code":"70390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8151.690,"maximum":8151.690,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":8151.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8151.690,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage ","code_information":[{"code":"31624","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15364.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, b ","code_information":[{"code":"0016M","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3489.630,"maximum":76673.060,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":3489.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOnExchange","standard_charge_dollar":3489.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":3559.420,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"SHOP","standard_charge_dollar":4885.480,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":6221.310,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":76673.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":76673.060,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":3559.420,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":3559.420,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":3489.630,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":3629.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3559.420,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":3489.630,"methodology":"fee schedule"}]}]},{"description":"Arteriovenous anastomosis, open; by upper arm cephalic vein transposition ","code_information":[{"code":"36818","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13748.000,"maximum":16279.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gelsyn-3 injection 0.1 mg ","code_information":[{"code":"01862","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":0.650,"maximum":0.670,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.650,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.670,"methodology":"fee schedule"}]}]},{"description":"Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; with transduodenal sphincterotomy or sphincteroplasty ","code_information":[{"code":"47425","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mammary ductogram or galactogram, single duct, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"77053","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":198.610,"maximum":231.570,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":198.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":229.950,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":231.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":208.410,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":231.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":231.570,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":229.950,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation ","code_information":[{"code":"21330","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.000,"maximum":19440.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8922.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":5005.800,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16416.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19440.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter superior and inferior vena cava prosthetic valve implantation (ie, caval valve implantation ºCAVI»); open femoral vein approach ","code_information":[{"code":"0806T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cholecystography, oral contrast ","code_information":[{"code":"341","type":"RC"},{"code":"74290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6295.280,"maximum":6295.280,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":6295.280,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6295.280,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) ","code_information":[{"code":"31629","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":6929.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) ","code_information":[{"code":"481","type":"RC"},{"code":"65600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":3149.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy ","code_information":[{"code":"54130","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound bone density measurement and interpretation, peripheral site(s), any method ","code_information":[{"code":"615","type":"RC"},{"code":"76977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity ","code_information":[{"code":"329","type":"RC"},{"code":"76883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC ","code_information":[{"code":"273","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21892.530,"maximum":22569.620,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":21892.530,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":22569.620,"methodology":"fee schedule"}]}]},{"description":"Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"155","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5552.000,"methodology":"per diem"}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8702.100,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9669.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15364.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"212","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating D ","code_information":[{"code":"0422U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3196.580,"maximum":8143.990,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3196.580,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8066.260,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3729.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3356.120,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3729.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3729.020,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8143.990,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; ischial tuberosity and greater trochanter of femur ","code_information":[{"code":"27078","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":26976.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) ","code_information":[{"code":"369","type":"RC"},{"code":"59100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1450.000,"maximum":16279.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1450.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3149.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation ","code_information":[{"code":"610","type":"RC"},{"code":"76776","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3730.960,"maximum":3730.960,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3730.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3730.960,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy ","code_information":[{"code":"31239","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.000,"maximum":28998.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6193.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transluminal coronary mechanical aspiration thrombectomy (List separately in addition to code for primary procedure) ","code_information":[{"code":"92973","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":52267.000,"maximum":60107.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":52267.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":60107.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed ","code_information":[{"code":"369","type":"RC"},{"code":"43210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.000,"maximum":35081.000,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":9438.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5562.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9236.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6929.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions ","code_information":[{"code":"614","type":"RC"},{"code":"77768","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9178.330,"maximum":9178.330,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9178.330,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9178.330,"methodology":"fee schedule"}]}]},{"description":"Diagnostic digital breast tomosynthesis; bilateral ","code_information":[{"code":"339","type":"RC"},{"code":"77062","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3962.120,"maximum":3962.120,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3962.120,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3962.120,"methodology":"fee schedule"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment ","code_information":[{"code":"321","type":"RC"},{"code":"77085","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19985.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC 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logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Natalizumab injection ","code_information":[{"code":"09126","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":23.780,"maximum":24.510,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":23.780,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":24.510,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; methemoglobin, quantitative 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be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":22781.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26976.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of symblepharon; conjunctivoplasty, without graft ","code_information":[{"code":"68330","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24489.000,"maximum":28998.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":3465.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6298.000,"methodology":"case 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procedure logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":1521.900,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1691.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5851.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":8934.300,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9927.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18158.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13748.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16279.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"167","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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logic."},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":30033.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53020.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24489.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28998.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per 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profiles","setting":"outpatient","minimum":162.060,"maximum":188.960,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":162.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":187.640,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":188.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":170.060,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":188.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":188.960,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":187.640,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited ","code_information":[{"code":"403","type":"RC"},{"code":"76642","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3032.810,"maximum":3032.810,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3032.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3032.810,"methodology":"fee schedule"}]}]},{"description":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count ","code_information":[{"code":"85025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.920,"maximum":170.700,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7.770,"methodology":"fee schedule"},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":6.920,"methodology":"fee 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","code_information":[{"code":"309","type":"RC"},{"code":"81333","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.370,"maximum":574.170,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.370,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":568.690,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":262.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":236.610,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":262.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":262.900,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":574.170,"methodology":"fee schedule"}]}]},{"description":"Open repair of infrarenal aortic aneurysm or 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","code_information":[{"code":"87485","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":32.980,"maximum":84.030,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.980,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83.230,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HPN","standard_charge_dollar":34.630,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":38.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.480,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":84.030,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":48.34,"standard_charge_algorithm":"Reimbursement will be 48.34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":26.15,"standard_charge_algorithm":"Reimbursement will be 26.15% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":14712.360,"methodology":"fee schedule"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":7757.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.80,"standard_charge_algorithm":"Reimbursement will be 42.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":51.50,"standard_charge_algorithm":"Reimbursement will be 51.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13835.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.80,"standard_charge_algorithm":"Reimbursement will be 61.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":14146.500,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11851.710,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions ","code_information":[{"code":"320","type":"RC"},{"code":"74178","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":484.500,"maximum":564.900,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":484.500,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":560.940,"methodology":"fee 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procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC ","code_information":[{"code":"203","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per 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be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3609.000,"maximum":5552.000,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4441.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3609.000,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5552.000,"methodology":"per diem"},{"payer_name":"Harvard 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multiple procedure logic."},{"payer_name":"Anthem","plan_name":"IndividualOffExhange","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1553.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2624.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5019.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5943.000,"methodology":"case rate","additional_payer_notes":"The rate 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