{"hospital_name":"FAIRVIEW PARK HOSPITAL","last_updated_on":"2026-03-01","version":"3.0.0","location_name":["FAIRVIEW PARK HOSPITAL"],"hospital_address":["200 INDUSTRIAL BLVD, DUBLIN, GA, 31021"],"license_information":{"license_number":"087-594","state":"GA"},"type_2_npi":["1285688234"],"attestation":{"attestation":"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. 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":"Bradley Griffin"},"standard_charge_information":[{"description":"Bradykinin ","code_information":[{"code":"82286","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4.820,"maximum":6.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.680,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.160,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s ","code_information":[{"code":"29880","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7242.700,"maximum":7242.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7242.700,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, anus ","code_information":[{"code":"46999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2292.690,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":2340.460,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":2388.220,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2292.690,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":2340.460,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":2388.220,"methodology":"fee schedule"}]}]},{"description":"Colectomy, partial; with anastomosis ","code_information":[{"code":"44140","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon ","code_information":[{"code":"309","type":"RC"},{"code":"86480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.950,"maximum":73.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":57.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":68.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":57.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":68.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":61.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":73.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":61.980,"methodology":"fee schedule"}]}]},{"description":"Venography, epidural, radiological supervision and interpretation ","code_information":[{"code":"323","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":103.520,"maximum":125.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":103.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":117.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":103.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":125.890,"methodology":"fee schedule"}]}]},{"description":"Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate ","code_information":[{"code":"362","type":"RC"},{"code":"67882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation ","code_information":[{"code":"26776","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"201","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8270.660,"maximum":8270.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8270.660,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8947.180,"maximum":8947.180,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8947.180,"methodology":"fee schedule"}]}]},{"description":"Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) ","code_information":[{"code":"324","type":"RC"},{"code":"78014","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":434.940,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":434.940,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle ","code_information":[{"code":"27630","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal traction ","code_information":[{"code":"27517","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection procedure for discography, each level; lumbar ","code_information":[{"code":"362","type":"RC"},{"code":"62290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium ","code_information":[{"code":"409","type":"RC"},{"code":"75571","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":36.210,"maximum":44.040,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":41.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44.040,"methodology":"fee schedule"}]}]},{"description":"Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary proce ","code_information":[{"code":"361","type":"RC"},{"code":"63066","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Aortography, abdominal, by serialography, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75625","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":84.210,"maximum":102.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":84.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":95.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":84.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":102.410,"methodology":"fee schedule"}]}]},{"description":"Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated ","code_information":[{"code":"40801","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Intravenous infusion, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, who e ","code_information":[{"code":"M0224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1132.880,"maximum":1180.080,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1156.480,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":1180.080,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1132.880,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":1156.480,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":1180.080,"methodology":"fee schedule"}]}]},{"description":"Factor ix recombinan rixu ","code_information":[{"code":"01467","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.680,"maximum":1.680,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":1.680,"methodology":"fee schedule"}]}]},{"description":"DEPRESSIVE NEUROSES ","code_information":[{"code":"114","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8273.520,"maximum":8273.520,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8273.520,"methodology":"fee schedule"}]}]},{"description":"Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs by quantitative reverse transcription polymerase chain reaction, urine, reported as no molecular evidence, low-, moderate- or ele ","code_information":[{"code":"0424U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":896.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; simple ","code_information":[{"code":"324","type":"RC"},{"code":"77761","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":590.190,"maximum":717.760,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":590.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":669.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":590.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":717.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) ","code_information":[{"code":"310","type":"RC"},{"code":"81273","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":124.870,"maximum":147.350,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":124.870,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":147.350,"methodology":"fee schedule"}]}]},{"description":"Open closure of major bronchial fistula ","code_information":[{"code":"32815","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9104.020,"maximum":9104.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9104.020,"methodology":"fee schedule"}]}]},{"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":2205.000,"maximum":40306.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12517.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14199.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12517.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15225.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14688.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3906.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3245.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3869.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2987.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":39140.000,"methodology":"case rate"}]}]},{"description":"Unlisted laparoscopy procedure, ureter ","code_information":[{"code":"50949","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic ","code_information":[{"code":"362","type":"RC"},{"code":"63055","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code) ","code_information":[{"code":"15854","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27047.840,"maximum":27047.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27047.840,"methodology":"fee schedule"}]}]},{"description":"Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 ºCDK1», IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score fo ","code_information":[{"code":"0012M","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":710.600,"maximum":896.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"74182","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":313.300,"maximum":381.020,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":313.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":355.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":313.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":381.020,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10136.980,"maximum":10136.980,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10136.980,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; ","code_information":[{"code":"615","type":"RC"},{"code":"75557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy ","code_information":[{"code":"58956","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction of lesion, palate or uvula (thermal, cryo or chemical) ","code_information":[{"code":"369","type":"RC"},{"code":"42160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Sirolimus ","code_information":[{"code":"307","type":"RC"},{"code":"80195","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.840,"maximum":16.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.730,"methodology":"fee schedule"}]}]},{"description":"Valvotomy, pulmonary valve, open heart, with cardiopulmonary bypass ","code_information":[{"code":"33474","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Venography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75820","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":64.870,"maximum":78.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":64.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":73.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":64.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":78.890,"methodology":"fee schedule"}]}]},{"description":"Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed ","code_information":[{"code":"46262","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gastrointestinal protein loss ","code_information":[{"code":"400","type":"RC"},{"code":"78282","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"INJECT SPINE CERV/THORACIC ","code_information":[{"code":"62310","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary ","code_information":[{"code":"37259","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17190.890,"maximum":17190.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17190.890,"methodology":"fee schedule"}]}]},{"description":"Percutaneous balloon valvuloplasty; pulmonary valve ","code_information":[{"code":"481","type":"RC"},{"code":"92990","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":42601.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35022.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":39729.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35022.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42601.500,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":41097.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10300.000,"methodology":"case rate"}]}]},{"description":"Creatine ","code_information":[{"code":"302","type":"RC"},{"code":"82540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.340,"maximum":5.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.640,"methodology":"fee schedule"}]}]},{"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":"341","type":"RC"},{"code":"75563","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":932.270,"maximum":932.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":932.270,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments ","code_information":[{"code":"63103","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) ","code_information":[{"code":"360","type":"RC"},{"code":"45398","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES ","code_information":[{"code":"132","type":"RC"},{"code":"748","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11455.800,"maximum":11455.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11455.800,"methodology":"fee schedule"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC ","code_information":[{"code":"214","type":"RC"},{"code":"419","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11302.530,"maximum":11302.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11302.530,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6616.790,"maximum":6616.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6616.790,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views ","code_information":[{"code":"329","type":"RC"},{"code":"73503","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":18.090,"maximum":22.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.000,"methodology":"fee schedule"}]}]},{"description":"Inj., patisiran, 0.1 mg ","code_information":[{"code":"09180","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":96.970,"maximum":96.970,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":96.970,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List ","code_information":[{"code":"22552","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique ","code_information":[{"code":"301","type":"RC"},{"code":"87495","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.080,"maximum":35.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":28.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":33.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":28.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33.030,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30.030,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material ","code_information":[{"code":"342","type":"RC"},{"code":"72141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"BONE DISEASES AND ARTHROPATHIES WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10807.080,"maximum":10807.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10807.080,"methodology":"fee schedule"}]}]},{"description":"Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy ","code_information":[{"code":"50574","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open ","code_information":[{"code":"367","type":"RC"},{"code":"49020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion ","code_information":[{"code":"36590","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10300.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10300.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1519.340,"maximum":1519.340,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1519.340,"methodology":"fee schedule"}]}]},{"description":"Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein ","code_information":[{"code":"360","type":"RC"},{"code":"36800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10300.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10300.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Bone graft with microvascular anastomosis; fibula ","code_information":[{"code":"20955","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncology (colorectal cancer), image analysis with artificial intelligence assessment of 4 histologic and immunohistochemical features (CD3 and CD8 within tumor-stroma border and tumor core), tissue, r ","code_information":[{"code":"0261U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2513.250,"maximum":2965.630,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2513.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2965.630,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"400","type":"RC"},{"code":"73706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":547.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":450.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":510.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":450.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":547.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; aortoiliac ","code_information":[{"code":"35637","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, ","code_information":[{"code":"0007U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":106.990,"maximum":135.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":106.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":125.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":106.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":125.870,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":114.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":135.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":114.430,"methodology":"fee schedule"}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) ","code_information":[{"code":"44370","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) ","drug_information":{"unit":5.100000000000000e+002,"type":"ME"},"code_information":[{"code":"636","type":"RC"},{"code":"902149","type":"CDM"},{"code":"Q0139","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.770,"maximum":0.770,"gross_charge":2004.75,"discounted_cash":2004.75,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.770,"methodology":"fee schedule"}]}]},{"description":"Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) ","code_information":[{"code":"52317","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age ","code_information":[{"code":"36570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":11644.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":11644.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":8733.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":11644.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11644.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":6716.890,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8911.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":8400.000,"methodology":"case rate"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":6853.970,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":6579.810,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":6716.890,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":6853.970,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8679.860,"maximum":8679.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8679.860,"methodology":"fee schedule"}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITH CC ","code_information":[{"code":"035","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":18607.380,"maximum":18607.380,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18607.380,"methodology":"fee schedule"}]}]},{"description":"Complete cbc, automated (hgb, hct, rbc, wbc, without platelet count) and automated wbc differential count ","code_information":[{"code":"925","type":"RC"},{"code":"G0306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7.260,"maximum":9.170,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.770,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed ","code_information":[{"code":"307","type":"RC"},{"code":"87625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.910,"maximum":47.850,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":44.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44.610,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":40.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":47.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":40.550,"methodology":"fee schedule"}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8361.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"}]}]},{"description":"Mastotomy with exploration or drainage of abscess, deep ","code_information":[{"code":"19020","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anoscopy, high resolution (hra) (with magnification and chemical agent enhancement); with biopsy(ies) ","code_information":[{"code":"369","type":"RC"},{"code":"G6028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fine needle aspiration biopsy, without imaging guidance; first lesion ","code_information":[{"code":"10021","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus ","code_information":[{"code":"302","type":"RC"},{"code":"87912","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":240.720,"maximum":303.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":240.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":283.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":240.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":283.190,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":257.450,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":303.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":257.450,"methodology":"fee schedule"}]}]},{"description":"Excision, lesion of palate, uvula; without closure ","code_information":[{"code":"42104","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH MCC One Day Stay","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Cystourethroplasty with unilateral or bilateral ureteroneocystostomy ","code_information":[{"code":"360","type":"RC"},{"code":"51820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29800","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Compatibility test each unit; immediate spin technique ","code_information":[{"code":"807049","type":"CDM"},{"code":"86920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":182.140,"maximum":448.880,"gross_charge":1050.25,"discounted_cash":1050.25,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":182.140,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":448.880,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":430.920,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":448.880,"methodology":"fee schedule"}]}]},{"description":"Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) ","code_information":[{"code":"42145","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, surgical, with maxillary antrostomy; ","code_information":[{"code":"31256","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) ","code_information":[{"code":"26500","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, transvaginal ","code_information":[{"code":"76817","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":112.600,"maximum":112.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":112.600,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":112.600,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":112.600,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":112.600,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":112.600,"methodology":"fee schedule"}]}]},{"description":"Oncology (urothelial carcinoma),DNA,quantitative methylationspecific PCR of 2 genes (ONECUT2,VIM),algorithmic analysis reported as positive or negative ","code_information":[{"code":"0465U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1812.040,"maximum":2286.850,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1812.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2131.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1812.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2131.810,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1938.010,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2286.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1938.010,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"039","type":"MS-DRG"},{"code":"120","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9945.920,"maximum":9945.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9945.920,"methodology":"fee schedule"}]}]},{"description":"Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) ","code_information":[{"code":"27860","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"T cells; absolute CD4 and CD8 count, including ratio ","code_information":[{"code":"312","type":"RC"},{"code":"86360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46.980,"maximum":55.440,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":46.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":55.440,"methodology":"fee schedule"}]}]},{"description":" Intensive Care Unit General Classification  ","code_information":[{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","payers_information":[{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib ºplatelet», alpha polypeptide ºGPIba») (eg, neonatal alloimmune thrombocytopenia ºNAIT», post-transfusion purpura), gene analysis, c ","code_information":[{"code":"311","type":"RC"},{"code":"81106","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":122.220,"maximum":144.220,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":122.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":144.220,"methodology":"fee schedule"}]}]},{"description":"Coronary artery bypass, vein only; single coronary venous graft ","code_information":[{"code":"33510","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC One Day Stay","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Cricotracheal resection ","code_information":[{"code":"31592","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9885.330,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9885.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"191","type":"RC"},{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Tubotubal anastomosis ","code_information":[{"code":"58750","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone age studies ","code_information":[{"code":"400","type":"RC"},{"code":"77072","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":23.090,"maximum":28.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":26.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28.080,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"143","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16446.650,"maximum":16446.650,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16446.650,"methodology":"fee schedule"}]}]},{"description":"HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) ","code_information":[{"code":"302","type":"RC"},{"code":"81361","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":163.450,"maximum":206.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":163.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":192.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":163.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":192.290,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":174.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":206.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":174.810,"methodology":"fee schedule"}]}]},{"description":"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC ","code_information":[{"code":"164","type":"RC"},{"code":"746","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13949.440,"maximum":13949.440,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13949.440,"methodology":"fee schedule"}]}]},{"description":"Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal ","code_information":[{"code":"499","type":"RC"},{"code":"55831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"27892","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Application, cast; plaster Velpeau ","code_information":[{"code":"29058","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drainage of abscess, cyst, hematoma from dentoalveolar structures ","code_information":[{"code":"41800","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Drainage of subdiaphragmatic or subphrenic abscess, open ","code_information":[{"code":"49040","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious disease (bacterial or viral), biochemical assays, tumor necrosis factor related apoptosis-inducing ligand interferon gamma induced protein-10, and C-reactive protein, serum, algorithm repor ","code_information":[{"code":"0351U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":243.570,"maximum":307.390,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":243.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":286.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":243.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":286.550,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":260.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":307.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":260.500,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater ","code_information":[{"code":"23071","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance spectroscopy ","code_information":[{"code":"403","type":"RC"},{"code":"76390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"SKIN DEBRIDEMENT WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9737.760,"maximum":9737.760,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9737.760,"methodology":"fee schedule"}]}]},{"description":"Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; ","code_information":[{"code":"69660","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"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":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1263.530,"maximum":1490.970,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1263.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1490.970,"methodology":"fee schedule"}]}]},{"description":"Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; ","code_information":[{"code":"15956","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of tumor, temporal bone ","code_information":[{"code":"360","type":"RC"},{"code":"69970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13017.710,"maximum":13017.710,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13017.710,"methodology":"fee schedule"}]}]},{"description":"External cannula declotting (separate procedure); with balloon catheter ","code_information":[{"code":"36861","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":10300.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10300.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed ","code_information":[{"code":"305","type":"RC"},{"code":"87625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.910,"maximum":47.850,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":44.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44.610,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":40.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":47.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":40.550,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed ","code_information":[{"code":"480","type":"RC"},{"code":"64454","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer ","code_information":[{"code":"27091","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7334.440,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7041.060,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition ","code_information":[{"code":"19286","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE ","code_information":[{"code":"211","type":"RC"},{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23770.030,"maximum":23770.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23770.030,"methodology":"fee schedule"}]}]},{"description":"Thymol turbidity, blood ","code_information":[{"code":"303","type":"RC"},{"code":"P2033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.630,"maximum":5.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.450,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.950,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21886.610,"maximum":21886.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21886.610,"methodology":"fee schedule"}]}]},{"description":"LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 2 STAGES WITHIN 14 DAYS; CERVICAL ","code_information":[{"code":"63198","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11891.200,"maximum":11891.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"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":"342","type":"RC"},{"code":"72083","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Liver imaging; static only ","code_information":[{"code":"341","type":"RC"},{"code":"78201","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":241.790,"maximum":1101.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":241.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":274.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":241.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":278.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1101.150,"methodology":"fee schedule"}]}]},{"description":"Excision or destruction of lesion of pharynx, any method ","code_information":[{"code":"362","type":"RC"},{"code":"42808","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Citrate ","code_information":[{"code":"306","type":"RC"},{"code":"82507","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.990,"maximum":32.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":30.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":32.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.800,"methodology":"fee schedule"}]}]},{"description":"Injection, vancomycin hydrochloride, 10 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J3373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.060,"maximum":0.060,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.060,"methodology":"fee schedule"}]}]},{"description":"Neurology (dementia), beta amyloid (A?40, A?42, A?42/40 ratio), tau-protein phosphorylated at residue (eg, pTau217), neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP), ","code_information":[{"code":"0568U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.090,"maximum":1345.500,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":905.970,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":923.910,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":914.940,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":870.090,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":905.970,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":905.970,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":905.970,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":1345.500,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":914.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":914.940,"methodology":"fee schedule"}]}]},{"description":"Cholesterol, serum or whole blood, total ","code_information":[{"code":"301","type":"RC"},{"code":"82465","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.070,"maximum":5.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.790,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.350,"methodology":"fee schedule"}]}]},{"description":"Voltage-gated calcium channel antibody, each ","code_information":[{"code":"300","type":"RC"},{"code":"86596","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.050,"maximum":20.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.400,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC ","code_information":[{"code":"446","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3688.810,"maximum":3993.050,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":3993.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":3688.810,"methodology":"fee schedule"}]}]},{"description":"Calcium; total ","code_information":[{"code":"314","type":"RC"},{"code":"82310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.160,"maximum":6.090,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.090,"methodology":"fee schedule"}]}]},{"description":"Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm ","code_information":[{"code":"54308","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, diathermy ","code_information":[{"code":"490","type":"RC"},{"code":"67227","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm ","code_information":[{"code":"14001","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus) ","code_information":[{"code":"87631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":82.990,"maximum":223.320,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":128.370,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":128.370,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":128.370,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":128.370,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":128.370,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":87.140,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":146.910,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":84.650,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":223.320,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":145.480,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":124.480,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":138.350,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":171.160,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":122.130,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":82.990,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":213.940,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":145.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":145.480,"methodology":"fee schedule"}]}]},{"description":"Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) ","code_information":[{"code":"46614","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection, heparin sodium, (heparin lock flush), per 10 units ","code_information":[{"code":"636","type":"RC"},{"code":"J1642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.040,"maximum":0.040,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.040,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS; M > 38.75 & M < 49.15 ","code_information":[{"code":"024","type":"RC"},{"code":"D2002","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17735.160,"maximum":17735.160,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":17735.160,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"358","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11531.360,"maximum":11531.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11531.360,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; sulfhemoglobin, quantitative ","code_information":[{"code":"306","type":"RC"},{"code":"83060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.230,"maximum":10.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.800,"methodology":"fee schedule"}]}]},{"description":"Laminectomy, with release of tethered spinal cord, lumbar ","code_information":[{"code":"63200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":4950.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"HExtracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary proced ","code_information":[{"code":"0300T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR BLADDER PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16654.810,"maximum":16654.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16654.810,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, shoulder area; single tendon ","code_information":[{"code":"23405","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, osseous survey, infant ","code_information":[{"code":"619","type":"RC"},{"code":"77076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm ","code_information":[{"code":"11603","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1769.330,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1806.190,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":1843.050,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1769.330,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":1806.190,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":1843.050,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, cervical; 2 or 3 views ","code_information":[{"code":"321","type":"RC"},{"code":"72040","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":41.570,"maximum":50.560,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":47.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.560,"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint ","code_information":[{"code":"26531","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"131","type":"RC"},{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24028.810,"maximum":24028.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24028.810,"methodology":"fee schedule"}]}]},{"description":"Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk ","code_information":[{"code":"36468","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with salpingostomy (salpingoneostomy) ","code_information":[{"code":"490","type":"RC"},{"code":"58673","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components ","code_information":[{"code":"43774","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":25853.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21254.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24111.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21254.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25853.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":24940.800,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16480.000,"methodology":"case rate"}]}]},{"description":"VEIN LIGATION AND STRIPPING ","code_information":[{"code":"174","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23361.560,"maximum":23361.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23361.560,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each ","code_information":[{"code":"26080","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy with biopsy; interphalangeal joint, each ","code_information":[{"code":"26110","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA ","code_information":[{"code":"126","type":"RC"},{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":48439.850,"maximum":48439.850,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":48439.850,"methodology":"fee schedule"}]}]},{"description":"Reconstructive repair of pectus excavatum or carinatum; open ","code_information":[{"code":"21740","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"70543","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":523.090,"maximum":523.090,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":523.090,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":523.090,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":523.090,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":523.090,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":523.090,"methodology":"fee schedule"}]}]},{"description":"Temporomandibular joint arthrography, radiological supervision and interpretation ","code_information":[{"code":"70332","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":607.860,"maximum":633.190,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":620.530,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":633.190,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":607.860,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":620.530,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":633.190,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each ","code_information":[{"code":"26750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":603.240,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":615.800,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":628.370,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":603.240,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":615.800,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":628.370,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"204","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"144","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6939.720,"maximum":6939.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6939.720,"methodology":"fee schedule"}]}]},{"description":"Dibucaine number ","code_information":[{"code":"312","type":"RC"},{"code":"82638","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.250,"maximum":14.460,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.460,"methodology":"fee schedule"}]}]},{"description":"Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method ","code_information":[{"code":"28298","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) ","code_information":[{"code":"27357","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PAIN SYNDROME; M > 26.75 & M < 37.15 ","code_information":[{"code":"118","type":"RC"},{"code":"D1602","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":16208.810,"maximum":18548.230,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":17712.720,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":16710.120,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":18548.230,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17545.620,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":16208.810,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16877.220,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":16877.220,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":16877.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":16710.120,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":18548.230,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":18548.230,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm ","code_information":[{"code":"11643","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older ","code_information":[{"code":"33954","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Rubeola ","code_information":[{"code":"300","type":"RC"},{"code":"87283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":56.850,"maximum":71.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":56.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":66.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":56.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":66.880,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":60.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":71.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":60.800,"methodology":"fee schedule"}]}]},{"description":"Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure ","code_information":[{"code":"310","type":"RC"},{"code":"88368","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":247.570,"maximum":291.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":247.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":291.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":247.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":291.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.260,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) ","code_information":[{"code":"619","type":"RC"},{"code":"71550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, pelvis or hip joint ","code_information":[{"code":"27299","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, pelvis; 1 or 2 views ","code_information":[{"code":"401","type":"RC"},{"code":"72170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT ","code_information":[{"code":"142","type":"RC"},{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":153768.810,"maximum":153768.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":153768.810,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm ","code_information":[{"code":"27618","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery ","code_information":[{"code":"42970","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), bone-substitute material for bone and/or soft tissue hardware fixation augmentation, including intraoperative imaging guidance, when performed ","code_information":[{"code":"0869T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"152","type":"RC"},{"code":"624","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10490.560,"maximum":10490.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10490.560,"methodology":"fee schedule"}]}]},{"description":"Puncture aspiration of abscess, hematoma, bulla, or cyst ","code_information":[{"code":"10160","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Red cell volume determination (separate procedure); single sampling ","code_information":[{"code":"340","type":"RC"},{"code":"78120","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":89.530,"maximum":103.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":89.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":101.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":89.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":103.210,"methodology":"fee schedule"}]}]},{"description":"Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure) ","code_information":[{"code":"24149","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH ","code_information":[{"code":"132","type":"RC"},{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17087.530,"maximum":17087.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17087.530,"methodology":"fee schedule"}]}]},{"description":"Meat fibers, feces ","code_information":[{"code":"305","type":"RC"},{"code":"89160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.530,"maximum":5.720,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.330,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.850,"methodology":"fee schedule"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITH CC ","code_information":[{"code":"172","type":"RC"},{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16598.490,"maximum":16598.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16598.490,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"039","type":"MS-DRG"},{"code":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9945.920,"maximum":9945.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9945.920,"methodology":"fee schedule"}]}]},{"description":"Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure ","code_information":[{"code":"314","type":"RC"},{"code":"88368","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":247.570,"maximum":291.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":247.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":291.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":247.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":291.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.260,"methodology":"fee schedule"}]}]},{"description":"Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart ","code_information":[{"code":"306","type":"RC"},{"code":"87084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.310,"maximum":31.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29.780,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":31.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.070,"methodology":"fee schedule"}]}]},{"description":"Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) ","code_information":[{"code":"360","type":"RC"},{"code":"43752","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY ","code_information":[{"code":"114","type":"RC"},{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13035.530,"maximum":13035.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13035.530,"methodology":"fee schedule"}]}]},{"description":"COMPLICATIONS OF TREATMENT WITHOUT CC/MCC ","code_information":[{"code":"219","type":"RC"},{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6473.500,"maximum":6473.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6473.500,"methodology":"fee schedule"}]}]},{"description":"Impression and custom preparation; speech aid prosthesis ","code_information":[{"code":"21084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8361.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":43401.950,"maximum":43401.950,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":43401.950,"methodology":"fee schedule"}]}]},{"description":"Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children ","code_information":[{"code":"0479T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2484.000,"maximum":7284.450,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Sialography, radiological supervision and interpretation ","code_information":[{"code":"359","type":"RC"},{"code":"70390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Triiodothyronine T3; reverse ","code_information":[{"code":"301","type":"RC"},{"code":"84482","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.740,"maximum":18.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.340,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.760,"methodology":"fee schedule"}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; extradural ","code_information":[{"code":"367","type":"RC"},{"code":"61607","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 cm or greater ","code_information":[{"code":"28047","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7334.440,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7041.060,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"}]}]},{"description":"Autoinflammatory disease (VEXAS syndrome), DNA, UBA1 gene mutations, targeted variant analysis (M41T, M41V, M41L, c. 118-2A>C, c.118-1G>C, c.118-9_118-2del, S56F, S621C) ","code_information":[{"code":"0500U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":164.000,"maximum":206.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":164.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":192.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":164.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":192.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":175.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":206.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":175.400,"methodology":"fee schedule"}]}]},{"description":"Gastric mucosa imaging ","code_information":[{"code":"400","type":"RC"},{"code":"78261","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography ","code_information":[{"code":"341","type":"RC"},{"code":"78635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":415.550,"maximum":1101.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":415.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":471.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":415.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":479.040,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1101.150,"methodology":"fee schedule"}]}]},{"description":"Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) ","code_information":[{"code":"43752","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular ne ","code_information":[{"code":"321","type":"RC"},{"code":"76937","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.720,"maximum":43.940,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":32.720,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":43.940,"methodology":"fee schedule"}]}]},{"description":"Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon ","code_information":[{"code":"25280","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm ","code_information":[{"code":"21011","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"209","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6372.270,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6372.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Thromboxane metabolite(s), including thromboxane if performed, urine ","code_information":[{"code":"300","type":"RC"},{"code":"84431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.830,"maximum":41.430,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.620,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.110,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation ","code_information":[{"code":"26645","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) ","code_information":[{"code":"340","type":"RC"},{"code":"77600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":310.320,"maximum":310.320,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.320,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"127","type":"RC"},{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24028.810,"maximum":24028.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24028.810,"methodology":"fee schedule"}]}]},{"description":"Impression and custom preparation; mandibular resection prosthesis ","code_information":[{"code":"21081","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"322","type":"RC"},{"code":"70470","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":162.280,"maximum":197.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":162.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":184.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":162.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":197.350,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery ","code_information":[{"code":"37255","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of posterior malleolus fracture, includes internal fixation, when performed ","code_information":[{"code":"27769","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate ","code_information":[{"code":"369","type":"RC"},{"code":"67882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) ","code_information":[{"code":"319","type":"RC"},{"code":"82952","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.920,"maximum":4.630,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.630,"methodology":"fee schedule"}]}]},{"description":"Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"11107","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique ","code_information":[{"code":"311","type":"RC"},{"code":"87481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":41.410,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC ","code_information":[{"code":"817","type":"MS-DRG"},{"code":"O4703","type":"ICD"}],"standard_charges":[{"setting":"inpatient","minimum":3090.000,"maximum":3090.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3090.000,"methodology":"per diem"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC One Day Stay","code_information":[{"code":"095","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod ","code_information":[{"code":"26392","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC ","code_information":[{"code":"172","type":"RC"},{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":42678.370,"maximum":42678.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":42678.370,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of humeral shaft fracture; without manipulation ","code_information":[{"code":"24500","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Biopsy, prostate, any approach, nonimaging-guided ","code_information":[{"code":"55705","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal and replacement of implanted vestibular device, unilateral ","code_information":[{"code":"0727T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10010","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual ","code_information":[{"code":"312","type":"RC"},{"code":"88120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":126.790,"maximum":149.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":126.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":149.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":126.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":149.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Patient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathol ","code_information":[{"code":"0794T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":1637.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Inj, bezlotoxumab, 10 mg ","code_information":[{"code":"09490","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":38.630,"maximum":38.630,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":38.630,"methodology":"fee schedule"}]}]},{"description":"Inj elivaldogene autoteme ","code_information":[{"code":"00906","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3084600.000,"maximum":3084600.000,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":3084600.000,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) ","code_information":[{"code":"618","type":"RC"},{"code":"73221","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":" Room & Board - Ward Detoxification  ","code_information":[{"code":"156","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2150.000,"maximum":2866.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2866.000,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":2150.000,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":2866.000,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2866.000,"methodology":"per diem"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":55245.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":46154.170,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":17398.910,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":46154.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":46154.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":46154.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":32967.270,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41680.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":47282.380,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":17743.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41680.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50700.300,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":21533.300,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":17571.170,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":14642.640,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":14642.640,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":17571.170,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":17571.170,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":17915.710,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25108.720,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17915.710,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":16709.840,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":18831.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17398.910,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":17398.910,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":17398.910,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":17226.640,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":17226.640,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":17226.640,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":17915.710,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":17915.710,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":25839.960,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18087.970,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":17226.640,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"AllPayerAppendix","standard_charge_dollar":55245.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16864.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":17226.640,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":17226.640,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":17571.170,"methodology":"fee schedule"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY ","code_information":[{"code":"157","type":"RC"},{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13035.530,"maximum":13035.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13035.530,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"137","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"Injection, donanemab-azbt, 2 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J0175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.970,"maximum":8.970,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.970,"methodology":"fee schedule"}]}]},{"description":"Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision ","code_information":[{"code":"20150","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Injection, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, ","code_information":[{"code":"Q0237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_percentage":20.20,"standard_charge_algorithm":"Reimbursement will be 20.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_percentage":20.60,"standard_charge_algorithm":"Reimbursement will be 20.6% 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":"Clover","plan_name":"MCR","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_percentage":20.40,"standard_charge_algorithm":"Reimbursement will be 20.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_percentage":19.40,"standard_charge_algorithm":"Reimbursement will be 19.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_percentage":20.20,"standard_charge_algorithm":"Reimbursement will be 20.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_percentage":20.20,"standard_charge_algorithm":"Reimbursement will be 20.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_percentage":20.20,"standard_charge_algorithm":"Reimbursement will be 20.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":20.40,"standard_charge_algorithm":"Reimbursement will be 20.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"VACCN","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_percentage":20.40,"standard_charge_algorithm":"Reimbursement will be 20.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administe ","code_information":[{"code":"481","type":"RC"},{"code":"62264","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Lipoprotein, blood; electrophoretic separation and quantitation ","code_information":[{"code":"314","type":"RC"},{"code":"83700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.260,"maximum":13.290,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.260,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.290,"methodology":"fee schedule"}]}]},{"description":"ENDOBRONCHIAL US ADD-ON ","code_information":[{"code":"31620","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, complex, trunk; 1.1 cm to 2.5 cm ","code_information":[{"code":"13100","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical; with concha bullosa resection ","code_information":[{"code":"31240","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Russell viper venom time (includes venom); undiluted ","code_information":[{"code":"302","type":"RC"},{"code":"85612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.350,"maximum":20.640,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.490,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) ","code_information":[{"code":"21206","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Excision or fulguration of carcinoma of urethra ","code_information":[{"code":"480","type":"RC"},{"code":"53220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Injection, interferon beta-1a, 30 mcg ","code_information":[{"code":"892","type":"RC"},{"code":"J1826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7264.400,"maximum":7264.400,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7264.400,"methodology":"fee schedule"}]}]},{"description":"AICD LEAD PROCEDURES ","code_information":[{"code":"200","type":"RC"},{"code":"265","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27359.370,"maximum":27359.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27359.370,"methodology":"fee schedule"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE ","code_information":[{"code":"7104","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":40874.220,"maximum":61311.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":40874.220,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":41691.700,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":61311.330,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":40874.220,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":40874.220,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":40874.220,"methodology":"fee schedule"}]}]},{"description":"Transcervical catheterization of fallopian tube, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"74742","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":38.050,"maximum":46.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":38.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":43.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":38.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":46.280,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material ","code_information":[{"code":"612","type":"RC"},{"code":"70480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Colpocentesis (separate procedure) ","code_information":[{"code":"57020","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC ","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4635.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4635.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"Percutaneous balloon valvuloplasty; mitral valve ","code_information":[{"code":"480","type":"RC"},{"code":"92987","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4178.000,"maximum":42601.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35022.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":39729.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35022.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42601.500,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":41097.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7448.720,"maximum":7448.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7448.720,"methodology":"fee schedule"}]}]},{"description":"ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"304","type":"RC"},{"code":"81181","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting ","code_information":[{"code":"20604","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"71270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":290.810,"maximum":290.810,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":290.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":290.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":290.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":290.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":290.810,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC Pediatric","code_information":[{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":65780.920,"maximum":92090.770,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":92090.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":92090.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":92090.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":92090.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":65780.920,"methodology":"fee schedule"}]}]},{"description":"Bilirubin; feces, qualitative ","code_information":[{"code":"311","type":"RC"},{"code":"82252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.560,"maximum":5.380,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.380,"methodology":"fee schedule"}]}]},{"description":"Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access ","code_information":[{"code":"361","type":"RC"},{"code":"36595","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10300.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10300.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); ","code_information":[{"code":"60540","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Excision of tendon, palm, flexor or extensor, single, each tendon ","code_information":[{"code":"26170","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Volatiles (eg, acetic anhydride, diethylether) ","code_information":[{"code":"301","type":"RC"},{"code":"805313","type":"CDM"},{"code":"84600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.000,"maximum":20.190,"gross_charge":228.25,"discounted_cash":228.25,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.110,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC ","code_information":[{"code":"025","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":33978.430,"maximum":33978.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33978.430,"methodology":"fee schedule"}]}]},{"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":1182.000,"maximum":37080.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7705.530,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8741.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7705.530,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9372.930,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":9041.920,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":37080.000,"methodology":"case rate"}]}]},{"description":"Fat stain, feces, urine, or respiratory secretions ","code_information":[{"code":"311","type":"RC"},{"code":"89125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.880,"maximum":6.940,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.940,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic ","code_information":[{"code":"22532","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8860.930,"maximum":8860.930,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8860.930,"methodology":"fee schedule"}]}]},{"description":"Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger ","code_information":[{"code":"26428","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted magnetic resonance procedure (eg, diagnostic, interventional) ","code_information":[{"code":"401","type":"RC"},{"code":"76498","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9719.940,"maximum":9719.940,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9719.940,"methodology":"fee schedule"}]}]},{"description":"Urethroplasty; second stage (formation of urethra), including urinary diversion ","code_information":[{"code":"53405","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"312","type":"RC"},{"code":"81183","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":137.000,"maximum":161.660,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, nervous system ","code_information":[{"code":"490","type":"RC"},{"code":"64999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Debridement of nail(s) by any method(s); 1 to 5 ","code_information":[{"code":"11720","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Keratoplasty (corneal transplant); anterior lamellar ","code_information":[{"code":"480","type":"RC"},{"code":"65710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Ureteral reflux study (radiopharmaceutical voiding cystogram) ","code_information":[{"code":"359","type":"RC"},{"code":"78740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Inj brixadi, more than 7 ","code_information":[{"code":"733","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1629.800,"maximum":2520.320,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1697.010,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":1730.620,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1764.220,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":1713.820,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1680.210,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1764.220,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1764.220,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":1629.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1697.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":1697.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":1697.010,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":1680.210,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":1680.210,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1680.210,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":2520.320,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1764.220,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":1680.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1713.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":1680.210,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":1713.820,"methodology":"fee schedule"}]}]},{"description":"Autologous muscle cell therapy, harvesting of muscle progenitor cells, including ultrasound guidance, when performed ","code_information":[{"code":"0999T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, with synovectomy, knee; anterior OR posterior ","code_information":[{"code":"27334","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List sep ","code_information":[{"code":"33572","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26079.030,"maximum":26079.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26079.030,"methodology":"fee schedule"}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual ","code_information":[{"code":"41015","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming ","code_information":[{"code":"369","type":"RC"},{"code":"64566","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC ","code_information":[{"code":"132","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13559.500,"maximum":13559.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13559.500,"methodology":"fee schedule"}]}]},{"description":"Injection, c-1 esterase inhibitor (human), berinert, 10 units ","code_information":[{"code":"891","type":"RC"},{"code":"J0597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":163.100,"maximum":163.100,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":163.100,"methodology":"fee schedule"}]}]},{"description":"Transurethral destruction of prostate tissue; by radiofrequency thermotherapy ","code_information":[{"code":"53852","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia ","code_information":[{"code":"54316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":11907.990,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":11669.830,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":11907.990,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":11431.670,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":11669.830,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":11907.990,"methodology":"fee schedule"}]}]},{"description":"Aquaporin-4 (neuromyelitis optica ºNMO») antibody; flow cytometry (ie, fluorescence-activated cell sorting ºFACS»), each ","code_information":[{"code":"311","type":"RC"},{"code":"86053","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.730,"maximum":44.520,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":37.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":44.520,"methodology":"fee schedule"}]}]},{"description":"Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes comparison to previously performed baseline analyses; without cell selection ","code_information":[{"code":"301","type":"RC"},{"code":"81267","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.980,"maximum":244.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":193.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":228.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":193.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":228.210,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":207.460,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":244.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":207.460,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor, radial head or neck ","code_information":[{"code":"24152","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, with synovectomy, knee; anterior OR posterior ","code_information":[{"code":"27334","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological su ","code_information":[{"code":"36228","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cerclage of cervix, during pregnancy; abdominal ","code_information":[{"code":"481","type":"RC"},{"code":"59325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy ","code_information":[{"code":"61543","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CONCUSSION WITHOUT CC/MCC ","code_information":[{"code":"090","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8416.170,"maximum":9110.280,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":9110.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":8416.170,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, elbow, surgical; with removal of loose body or foreign body ","code_information":[{"code":"29834","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6315.830,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC ","code_information":[{"code":"167","type":"RC"},{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8916.530,"maximum":8916.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8916.530,"methodology":"fee schedule"}]}]},{"description":"Oncoprotein; HER-2/neu ","code_information":[{"code":"301","type":"RC"},{"code":"83950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":60.220,"maximum":76.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":60.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":70.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":60.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":70.850,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":76.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":64.410,"methodology":"fee schedule"}]}]},{"description":"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc ","code_information":[{"code":"301","type":"RC"},{"code":"U0002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":47.970,"maximum":60.550,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":47.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":47.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":56.440,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":51.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":60.550,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":51.310,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), ","code_information":[{"code":"22633","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Fibrin(ogen) degradation (split) products (FDP) (FSP); paracoagulation ","code_information":[{"code":"85366","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.120,"maximum":120.690,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":72.410,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":81.260,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":72.410,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":72.410,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":72.410,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":72.410,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":12.730,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":82.870,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":12.360,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":84.480,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":113.450,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":82.070,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":18.180,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":84.480,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":84.480,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":78.050,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":96.550,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":81.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":81.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":81.260,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":68.900,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":12.120,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":120.690,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":84.480,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":82.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":82.070,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, metacarpophalangeal joint; each joint ","code_information":[{"code":"26530","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC ","code_information":[{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":74814.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":68106.220,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":24984.070,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":68106.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":68106.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":68106.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":48647.300,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":61505.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":69771.030,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":25478.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":61505.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":74814.600,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":30920.880,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":25231.430,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":21026.190,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":21026.190,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":25231.430,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":25231.430,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":33821.870,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25726.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":37051.040,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":25726.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":23994.600,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":27788.280,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24984.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":24984.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":24984.070,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":24736.700,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":24736.700,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":24736.700,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":34512.110,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":36152.210,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":29796.320,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":35808.840,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":27427.750,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":25726.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":33131.630,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":25726.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":33821.870,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":37105.050,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":25973.540,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":24736.700,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":34512.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13596.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24217.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":24736.700,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":24736.700,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":25231.430,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging, breast, without contrast material; unilateral ","code_information":[{"code":"323","type":"RC"},{"code":"77046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.030,"maximum":362.310,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":297.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":337.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":297.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":362.310,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":245.030,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Thrombin time; titer ","code_information":[{"code":"302","type":"RC"},{"code":"85675","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.400,"maximum":8.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.540,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.850,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) ","code_information":[{"code":"23575","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Replacement of all or part of ureter by intestine segment, including intestine anastomosis ","code_information":[{"code":"50840","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access ","code_information":[{"code":"36595","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4178.000,"maximum":9657.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Repair recurrent femoral hernia; reducible ","code_information":[{"code":"49555","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Revision mastoidectomy; resulting in tympanoplasty ","code_information":[{"code":"361","type":"RC"},{"code":"69604","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, anterior chamber of eye (separate procedure); medication ","code_information":[{"code":"66030","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"External drainage, pseudocyst of pancreas, open ","code_information":[{"code":"48510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter intraoperative blood vessel microinfusion(s) (e.g., intraluminal, vascular wall and/or perivascular) therapy, any vessel, including radiological supervision and interpretation, when perf ","code_information":[{"code":"361","type":"RC"},{"code":"C9759","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":1637.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35081.250,"maximum":35081.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":35081.250,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"204","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6907.640,"maximum":6907.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6907.640,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"203","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7774.500,"maximum":7774.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7774.500,"methodology":"fee schedule"}]}]},{"description":"Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal ","code_information":[{"code":"67005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":5364.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":5257.110,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":5364.400,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":5149.820,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":5257.110,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":5364.400,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the eso ","code_information":[{"code":"43242","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteoplasty, facial bones; reduction ","code_information":[{"code":"21209","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Repair, flexor tendon, leg; primary, without graft, each tendon ","code_information":[{"code":"27658","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC ","code_information":[{"code":"144","type":"RC"},{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9629.410,"maximum":9629.410,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9629.410,"methodology":"fee schedule"}]}]},{"description":"Biopsy, prostate, transperineal, MRI-ultrasound-fusion guided, targeted lesion(s) only, first targeted lesion ","code_information":[{"code":"499","type":"RC"},{"code":"55712","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) ","code_information":[{"code":"31051","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"409","type":"RC"},{"code":"77423","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.600,"maximum":682.600,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"Costotransversectomy (separate procedure) ","code_information":[{"code":"21610","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I ","code_information":[{"code":"21160","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"036","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15415.830,"maximum":15415.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15415.830,"methodology":"fee schedule"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":31482.640,"maximum":31482.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":31482.640,"methodology":"fee schedule"}]}]},{"description":"Renin ","code_information":[{"code":"309","type":"RC"},{"code":"84244","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.560,"maximum":25.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.190,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":25.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.990,"methodology":"fee schedule"}]}]},{"description":"Venography, orbital, radiological supervision and interpretation ","code_information":[{"code":"615","type":"RC"},{"code":"75880","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":729.550,"maximum":729.550,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":729.550,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, spermatic cord ","code_information":[{"code":"499","type":"RC"},{"code":"55559","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral ","code_information":[{"code":"31574","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Excavation of a tooth resulting in the determination of non-restorability ","code_information":[{"code":"369","type":"RC"},{"code":"D2989","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Endovascular repair of thoracic aorta, including pre-procedure sizing and device selection, nonselective catheterization(s), all associated radiological supervision and interpretation; by deployment o ","code_information":[{"code":"33881","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed ","code_information":[{"code":"0909T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"806295","type":"CDM"},{"code":"93662","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4178.000,"maximum":9657.000,"gross_charge":15005.00,"discounted_cash":15005.00,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC ","code_information":[{"code":"204","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8696.250,"maximum":8696.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8696.250,"methodology":"fee schedule"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15413.690,"maximum":15413.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15413.690,"methodology":"fee schedule"}]}]},{"description":"Corneal relaxing incision for correction of surgically induced astigmatism ","code_information":[{"code":"490","type":"RC"},{"code":"65772","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out ","code_information":[{"code":"362","type":"RC"},{"code":"69661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Collection of capillary blood specimen (eg, finger, heel, ear stick) ","code_information":[{"code":"361","type":"RC"},{"code":"36416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Protoporphyrin, RBC; quantitative ","code_information":[{"code":"84202","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13.420,"maximum":16.930,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.790,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.350,"methodology":"fee schedule"}]}]},{"description":"Repair of iris, ciliary body (as for iridodialysis) ","code_information":[{"code":"360","type":"RC"},{"code":"66680","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS ","code_information":[{"code":"4221","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2606.290,"maximum":3909.430,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2606.290,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":2658.420,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":3909.430,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":2606.290,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2606.290,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2606.290,"methodology":"fee schedule"}]}]},{"description":"Trabeculostomy ab interno by laser; with use of ophthalmic endoscope ","code_information":[{"code":"0622T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7417.150,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Hep b ig, im ","code_information":[{"code":"01630","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":133.690,"maximum":133.690,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":133.690,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 1 view ","code_information":[{"code":"324","type":"RC"},{"code":"73501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.540,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":47.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":53.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":47.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":57.380,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":39.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Injection, ofatumumab, 10 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J9302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":133.790,"maximum":133.790,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":133.790,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32881.310,"maximum":32881.310,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":32881.310,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar ","code_information":[{"code":"329","type":"RC"},{"code":"72158","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":301.460,"maximum":366.620,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":301.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":341.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":301.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":366.620,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH CC ","code_information":[{"code":"148","type":"RC"},{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Drug Assay, presumptive, 30 or more drugs or metabolites, urine, liquid chromatography with tandem mass spectrometry using multiple reaction monitoring w drug or metabolite description, incl simple va ","code_information":[{"code":"0227U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":62.140,"maximum":73.330,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":62.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":73.330,"methodology":"fee schedule"}]}]},{"description":"Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein ","code_information":[{"code":"44715","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Rhinectomy; partial ","code_information":[{"code":"30150","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performed ","code_information":[{"code":"24579","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of malignant tumor of maxilla or zygoma ","code_information":[{"code":"21034","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair ","code_information":[{"code":"362","type":"RC"},{"code":"40810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less ","code_information":[{"code":"11300","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Creatinine; blood ","code_information":[{"code":"312","type":"RC"},{"code":"82565","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.120,"maximum":6.040,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.040,"methodology":"fee schedule"}]}]},{"description":"Radical excision external auditory canal lesion; without neck dissection ","code_information":[{"code":"367","type":"RC"},{"code":"69150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system ","code_information":[{"code":"62230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":12477.600,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":12228.050,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":12477.600,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":11978.500,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":12228.050,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":12477.600,"methodology":"fee schedule"}]}]},{"description":"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES ","code_information":[{"code":"141","type":"RC"},{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":25380.420,"maximum":25380.420,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":25380.420,"methodology":"fee schedule"}]}]},{"description":"Brachytherapy isodose plan; complex (calculationºs» made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) ","code_information":[{"code":"400","type":"RC"},{"code":"77318","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":440.260,"maximum":535.420,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":440.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":499.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":440.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":535.420,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (RH blood group) genotyping (RHD and RHCE), gene analysis Sanger/chain termination/conventional sequencing, RHD (Rh blood group D antigen) exons 1-10 and RHCE (Rhblood group CcEe anti ","code_information":[{"code":"0198U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":264.490,"maximum":333.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":264.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":311.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":264.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":311.170,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":333.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":282.880,"methodology":"fee schedule"}]}]},{"description":"Red cell volume determination (separate procedure); single sampling ","code_information":[{"code":"610","type":"RC"},{"code":"78120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Cetuximab injection ","code_information":[{"code":"9215","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":77.930,"maximum":120.510,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":81.150,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":82.750,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":84.360,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":81.950,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":80.340,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":84.360,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":84.360,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":77.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":81.150,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":81.150,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":81.150,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":80.340,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":80.340,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":80.340,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":120.510,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":84.360,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":80.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":81.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":80.340,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":81.950,"methodology":"fee schedule"}]}]},{"description":"Sugars (mono-, di-, and oligosaccharides); multiple qualitative, each specimen ","code_information":[{"code":"301","type":"RC"},{"code":"805997","type":"CDM"},{"code":"84377","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.140,"maximum":6.490,"gross_charge":823.75,"discounted_cash":823.75,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.050,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.500,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC One Day Stay","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Cholecystography, oral contrast ","code_information":[{"code":"409","type":"RC"},{"code":"74290","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":19.880,"maximum":24.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.180,"methodology":"fee schedule"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"316","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6428.590,"maximum":6428.590,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6428.590,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of posterior malleolus fracture; without manipulation ","code_information":[{"code":"27767","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) ","code_information":[{"code":"58400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Phenytoin; total ","code_information":[{"code":"302","type":"RC"},{"code":"80185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.390,"maximum":15.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.250,"methodology":"fee schedule"}]}]},{"description":"EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) ","code_information":[{"code":"309","type":"RC"},{"code":"81235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":303.480,"maximum":383.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":303.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":357.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":303.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":357.040,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":324.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":383.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":324.580,"methodology":"fee schedule"}]}]},{"description":"Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm ","code_information":[{"code":"13151","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24262.630,"maximum":24262.630,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24262.630,"methodology":"fee schedule"}]}]},{"description":"Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedur ","code_information":[{"code":"0450T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each ","code_information":[{"code":"360","type":"RC"},{"code":"47147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Quantitative differential pulmonary perfusion, including imaging when performed ","code_information":[{"code":"341","type":"RC"},{"code":"78597","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":44.840,"maximum":51.690,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":44.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":44.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":51.690,"methodology":"fee schedule"}]}]},{"description":"Revision or removal of neurostimulator electrode array, peripheral nerve, with integrated neurostimulator ","code_information":[{"code":"490","type":"RC"},{"code":"64598","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS ","code_information":[{"code":"7503","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7246.750,"maximum":10870.130,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":7246.750,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":7391.690,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":10870.130,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":7246.750,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":7246.750,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":7246.750,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D198JB","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"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":"302","type":"RC"},{"code":"87338","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.450,"maximum":16.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.380,"methodology":"fee schedule"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC ","code_information":[{"code":"201","type":"RC"},{"code":"558","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7933.470,"maximum":7933.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7933.470,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"124","type":"RC"},{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18042.060,"maximum":18042.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18042.060,"methodology":"fee schedule"}]}]},{"description":"Rare DS Whl Xom & Mitochdrl DNA Seq Alys Proband ","code_information":[{"code":"0214U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4885.000,"maximum":6165.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4885.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5747.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4885.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5747.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5224.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6165.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5224.600,"methodology":"fee schedule"}]}]},{"description":"Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis ","code_information":[{"code":"34831","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"136","type":"RC"},{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":39582.350,"maximum":39582.350,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":39582.350,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with dilation, subsequent ","code_information":[{"code":"31529","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA ","code_information":[{"code":"152","type":"RC"},{"code":"218","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":48439.850,"maximum":48439.850,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":48439.850,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis ","code_information":[{"code":"360","type":"RC"},{"code":"47800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array) ","code_information":[{"code":"360","type":"RC"},{"code":"61536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision or removal, lower esophageal sphincter neurostimulator pulse generator or receiver ","code_information":[{"code":"1015T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7992.000,"maximum":7992.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Pericardiectomy, subtotal or complete; without cardiopulmonary bypass ","code_information":[{"code":"33030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11624","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RHEUMATOID, OTHER ARTHRITIS; M=12-35 ","code_information":[{"code":"148","type":"RC"},{"code":"B1304","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":35819.470,"maximum":40989.300,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":39142.930,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":36927.290,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":40989.300,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":38773.660,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":35819.470,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":37296.570,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":37296.570,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":37296.570,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":36927.290,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":40989.300,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":40989.300,"methodology":"fee schedule"}]}]},{"description":"Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck ","code_information":[{"code":"51715","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any ","code_information":[{"code":"409","type":"RC"},{"code":"77001","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":114.540,"maximum":139.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":114.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":129.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":114.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":139.300,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, pelvis, with or without contrast material(s) ","code_information":[{"code":"618","type":"RC"},{"code":"72198","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":672.030,"maximum":672.030,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":672.030,"methodology":"fee schedule"}]}]},{"description":"Colpotomy; with exploration ","code_information":[{"code":"362","type":"RC"},{"code":"57000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"204","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8270.660,"maximum":8270.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8270.660,"methodology":"fee schedule"}]}]},{"description":"Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheteriz ","code_information":[{"code":"480","type":"RC"},{"code":"C7524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6315.830,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"}]}]},{"description":"Repair of hypospadias complication(s) (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty with flap or patch graft ","code_information":[{"code":"361","type":"RC"},{"code":"54344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management ","code_information":[{"code":"90869","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":783.080,"maximum":815.710,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":799.400,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":815.710,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":783.080,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":799.400,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":815.710,"methodology":"fee schedule"}]}]},{"description":"Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) ","code_information":[{"code":"21122","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Drainage of tendon sheath, digit and/or palm, each ","code_information":[{"code":"26020","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy with biopsy; interphalangeal joint ","code_information":[{"code":"28054","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) ","code_information":[{"code":"57283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":16095.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":15773.220,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":16095.120,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":15451.320,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":15773.220,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":16095.120,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Diagnostic digital breast tomosynthesis; unilateral ","code_information":[{"code":"321","type":"RC"},{"code":"77061","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":205.700,"maximum":205.700,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":205.700,"methodology":"fee schedule"}]}]},{"description":"Carbamazepine; total ","code_information":[{"code":"312","type":"RC"},{"code":"80156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.570,"maximum":17.190,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.190,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess ","code_information":[{"code":"45020","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITH CC ","code_information":[{"code":"202","type":"RC"},{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26706.370,"maximum":26706.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26706.370,"methodology":"fee schedule"}]}]},{"description":"Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 24 PFAS compounds by high-performance liquid chromatography ","code_information":[{"code":"0589U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":185.820,"maximum":234.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":185.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":218.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":185.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":218.610,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":198.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":234.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":198.740,"methodology":"fee schedule"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"132","type":"RC"},{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15786.520,"maximum":15786.520,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15786.520,"methodology":"fee schedule"}]}]},{"description":"Biopsy, prostate, transperineal, ultrasound-guided (ie, sextant, ultrasound-localized discrete lesionºs») ","code_information":[{"code":"480","type":"RC"},{"code":"55709","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":87238.880,"maximum":87238.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":87238.880,"methodology":"fee schedule"}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"100","type":"RC"},{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11723.120,"maximum":11723.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11723.120,"methodology":"fee schedule"}]}]},{"description":"Prostatotomy, external drainage of prostatic abscess, any approach; complicated ","code_information":[{"code":"480","type":"RC"},{"code":"55725","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"616","type":"RC"},{"code":"70498","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, wrist, surgical; internal fixation for fracture or instability ","code_information":[{"code":"29847","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"362","type":"RC"},{"code":"49452","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, adductor of hip, percutaneous (separate procedure) ","code_information":[{"code":"27000","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Unlisted diagnostic radiographic procedure ","code_information":[{"code":"614","type":"RC"},{"code":"76499","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus ","code_information":[{"code":"24134","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES ","code_information":[{"code":"153","type":"RC"},{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6233.260,"maximum":6233.260,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6233.260,"methodology":"fee schedule"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT ","code_information":[{"code":"212","type":"RC"},{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15316.730,"maximum":15316.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15316.730,"methodology":"fee schedule"}]}]},{"description":"URINARY STONES WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7138.610,"maximum":7138.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7138.610,"methodology":"fee schedule"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"126","type":"RC"},{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12988.480,"maximum":12988.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12988.480,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOT ","code_information":[{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":100890.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":91843.800,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":33186.190,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":91843.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":91843.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":91843.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":65602.720,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":82942.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":94088.850,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":33843.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":82942.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":100890.300,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":41072.010,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":33514.760,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":27928.970,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":27928.970,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":33514.760,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":33514.760,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":48334.060,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":34171.910,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":49964.720,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":34171.910,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":31871.880,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":37473.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":33186.190,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":33186.190,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":33186.190,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":32857.610,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":32857.610,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":32857.610,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":49320.470,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":51664.290,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":42581.230,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":51173.580,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":39196.360,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":34171.910,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10744.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":47347.650,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":34171.910,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":48334.060,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":49286.420,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":34500.490,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":32857.610,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":49320.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10391.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":32167.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":32857.610,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":32857.610,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":33514.760,"methodology":"fee schedule"}]}]},{"description":"Sugars (mono-, di-, and oligosaccharides); single quantitative, each specimen ","code_information":[{"code":"301","type":"RC"},{"code":"821944","type":"CDM"},{"code":"84378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.780,"maximum":13.610,"gross_charge":167.50,"discounted_cash":167.50,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.530,"methodology":"fee schedule"}]}]},{"description":"Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) ","code_information":[{"code":"490","type":"RC"},{"code":"50389","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion ","code_information":[{"code":"63620","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (pancreatic cancer), augumentative algorithmic analysis of 16 genes from previously sequenced RNA whole-transcriptome data, reported as probability of predicted molecular subtype ","code_information":[{"code":"0510U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":473.910,"maximum":559.210,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":473.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":559.210,"methodology":"fee schedule"}]}]},{"description":"Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluor ","code_information":[{"code":"49185","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"209","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9300.060,"maximum":9300.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9300.060,"methodology":"fee schedule"}]}]},{"description":"Transurethral destruction of prostate tissue; by radiofrequency thermotherapy ","code_information":[{"code":"53852","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"63295","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracoscopy, surgical; with esophagomyotomy (Heller type) ","code_information":[{"code":"32665","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Antibody; Nocardia ","code_information":[{"code":"307","type":"RC"},{"code":"86744","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.950,"maximum":18.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.590,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.990,"methodology":"fee schedule"}]}]},{"description":"Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery ","code_information":[{"code":"46917","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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, 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":"321","type":"RC"},{"code":"74251","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":411.160,"maximum":500.040,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":411.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":466.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":411.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":500.040,"methodology":"fee schedule"}]}]},{"description":"Antibody; herpes simplex, non-specific type test ","code_information":[{"code":"86694","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13.450,"maximum":16.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.390,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, include ","code_information":[{"code":"499","type":"RC"},{"code":"C9767","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele ","code_information":[{"code":"58270","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Psychiatry (eg, depression, anxiety, ADHD), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 ","code_information":[{"code":"0345U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1336.090,"maximum":1576.590,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1336.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1576.590,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique ","code_information":[{"code":"301","type":"RC"},{"code":"87475","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.750,"maximum":23.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.050,"methodology":"fee schedule"}]}]},{"description":"Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; younger than 5 years of age ","code_information":[{"code":"36568","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4178.000,"maximum":9657.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesio ","code_information":[{"code":"61737","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Syndactylization, toes (eg, webbing or Kelikian type procedure) ","code_information":[{"code":"28280","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) ","code_information":[{"code":"58110","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10797.810,"maximum":10797.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10797.810,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26312.860,"maximum":26312.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26312.860,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, knee; both knees, standing, anteroposterior ","code_information":[{"code":"404","type":"RC"},{"code":"73565","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11424","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Adrenocorticotropic hormone (ACTH) ","code_information":[{"code":"304","type":"RC"},{"code":"82024","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.110,"maximum":45.570,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.480,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":38.620,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":45.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38.620,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18144.010,"maximum":18144.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18144.010,"methodology":"fee schedule"}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"340","type":"RC"},{"code":"77054","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Oncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalinfixed paraffin-embedded ","code_information":[{"code":"0586U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2729.830,"maximum":3445.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2729.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3211.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2729.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3211.560,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3445.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2919.600,"methodology":"fee schedule"}]}]},{"description":"Proctectomy, partial, with anastomosis; abdominal and transsacral approach ","code_information":[{"code":"45114","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC ","code_information":[{"code":"032","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":16757.460,"maximum":16757.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16757.460,"methodology":"fee schedule"}]}]},{"description":"Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool ","code_information":[{"code":"314","type":"RC"},{"code":"87071","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.890,"maximum":11.670,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.890,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.670,"methodology":"fee schedule"}]}]},{"description":"Unlisted endocrine procedure, diagnostic nuclear medicine ","code_information":[{"code":"340","type":"RC"},{"code":"78099","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":848.520,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"11301","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pericardiotomy for removal of clot or foreign body (primary procedure) ","code_information":[{"code":"33020","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":11888.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Amphetamines; 1 or 2 ","code_information":[{"code":"80324","type":"CPT"},{"code":"822808","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":21.870,"maximum":32.800,"gross_charge":919.00,"discounted_cash":919.00,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":22.960,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":22.310,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":32.800,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":21.870,"methodology":"fee schedule"}]}]},{"description":"Biopsy; nasopharynx, visible lesion, simple ","code_information":[{"code":"42804","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8361.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":39179.580,"maximum":39179.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":39179.580,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBL ","code_information":[{"code":"6262","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1970.610,"maximum":2955.910,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":1970.610,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":2010.020,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":2955.910,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":1970.610,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1970.610,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1970.610,"methodology":"fee schedule"}]}]},{"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":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, metacarpophalangeal joint; each joint ","code_information":[{"code":"26530","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous ","code_information":[{"code":"369","type":"RC"},{"code":"65800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; ","code_information":[{"code":"25315","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"401","type":"RC"},{"code":"73723","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) ","code_information":[{"code":"362","type":"RC"},{"code":"52342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS ","code_information":[{"code":"127","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29118.030,"maximum":29118.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":29118.030,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrod ","code_information":[{"code":"0410T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the ","code_information":[{"code":"360","type":"RC"},{"code":"37248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention ","code_information":[{"code":"350","type":"RC"},{"code":"78707","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) ","code_information":[{"code":"303","type":"RC"},{"code":"87623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.810,"maximum":41.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy with biopsy; interphalangeal joint, each ","code_information":[{"code":"26110","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple ","code_information":[{"code":"55876","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Amphotericin b liposome i ","code_information":[{"code":"736","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":20.100,"maximum":31.080,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":20.930,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":21.340,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21.760,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":21.140,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21.760,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":20.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20.930,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":31.080,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.760,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":21.140,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) ","code_information":[{"code":"400","type":"RC"},{"code":"74181","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":180.280,"maximum":219.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":180.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":204.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":180.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":219.240,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes ","code_information":[{"code":"499","type":"RC"},{"code":"51585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"HInsertion of left atrial hemodynamic monitor; pressure sensor lead at time of insertion of pacing cardioverter-defibrillator pulse generator including radiological supervision and interpretation and ","code_information":[{"code":"0294T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9657.000,"maximum":9657.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"}]}]},{"description":"CEBPA (CCAAT/enhancer binding protein ºC/EBP», alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence ","code_information":[{"code":"310","type":"RC"},{"code":"81218","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":241.900,"maximum":285.440,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.440,"methodology":"fee schedule"}]}]},{"description":"Testosterone; total ","code_information":[{"code":"306","type":"RC"},{"code":"84403","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.130,"maximum":30.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":24.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":28.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":24.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28.390,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.810,"methodology":"fee schedule"}]}]},{"description":"OTITIS MEDIA AND URI WITHOUT MCC ","code_information":[{"code":"136","type":"RC"},{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6828.510,"maximum":6828.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6828.510,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap ","code_information":[{"code":"42845","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":1758.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12731.130,"maximum":12731.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12731.130,"methodology":"fee schedule"}]}]},{"description":"Injection procedure; radioactive tracer for identification of sentinel node ","code_information":[{"code":"360","type":"RC"},{"code":"38792","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, sirolimus protein-bound particles, 1 mg ","code_information":[{"code":"J9331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":94.570,"maximum":307.660,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":128.380,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":96.460,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":141.850,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":301.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":114.100,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":307.660,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":94.570,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":295.350,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":301.510,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":307.660,"methodology":"fee schedule"}]}]},{"description":"Prolactin ","code_information":[{"code":"306","type":"RC"},{"code":"84146","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.120,"maximum":22.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.380,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism ","code_information":[{"code":"301","type":"RC"},{"code":"87797","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.080,"maximum":35.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":28.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":33.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":28.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33.030,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30.030,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC ","code_information":[{"code":"988","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":34515.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":31420.700,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":12308.010,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":31420.700,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":31420.700,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":31420.700,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":22443.360,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":28375.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32188.760,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":12551.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":28375.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34515.600,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":15232.690,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":12429.870,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":10358.230,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":10358.230,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":12429.870,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12429.870,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":16564.400,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":12673.600,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17093.440,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":12673.600,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":11820.570,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":12820.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12308.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":12308.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":12308.010,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":12186.150,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":12186.150,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":12186.150,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":16902.450,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":17705.690,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":14592.860,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":17537.520,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":13432.850,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":12673.600,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":16226.350,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":12673.600,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":16564.400,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":18279.220,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12795.460,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":12186.150,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":16902.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13596.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11930.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":12186.150,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":12186.150,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":12429.870,"methodology":"fee schedule"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each ","code_information":[{"code":"367","type":"RC"},{"code":"63044","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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; lumbar ","code_information":[{"code":"22862","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) ","code_information":[{"code":"21146","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC ","code_information":[{"code":"202","type":"RC"},{"code":"988","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13282.900,"maximum":13282.900,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13282.900,"methodology":"fee schedule"}]}]},{"description":"Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg ","code_information":[{"code":"892","type":"RC"},{"code":"Q5112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":58.630,"maximum":58.630,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":58.630,"methodology":"fee schedule"}]}]},{"description":"Resection of ribs, extrapleural, all stages ","code_information":[{"code":"32900","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian arte ","code_information":[{"code":"324","type":"RC"},{"code":"75956","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":666.380,"maximum":666.380,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":666.380,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (incl ","code_information":[{"code":"33959","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Removal of implant body not requiring bone removal nor flap elevation ","code_information":[{"code":"750","type":"RC"},{"code":"D6105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22327.170,"maximum":22327.170,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22327.170,"methodology":"fee schedule"}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC ","code_information":[{"code":"210","type":"RC"},{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8821.000,"maximum":8821.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8821.000,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6085.700,"maximum":6085.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6085.700,"methodology":"fee schedule"}]}]},{"description":"Thoracic fascial plane block, unilateral; by injection(s), including imaging guidance, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"64466","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cranioplasty with autograft (includes obtaining bone grafts); larger than 5 cm diameter ","code_information":[{"code":"480","type":"RC"},{"code":"62147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Red cell antigen (Yt blood group) genotyping (YT), gene analysis, ACHE (acetylcholinesterase (Cartwright blood group)) exon 2 ","code_information":[{"code":"0201U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179.640,"maximum":277.800,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":187.050,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":194.460,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":190.760,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":194.460,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":277.800,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":194.460,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":194.460,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":179.640,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":187.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":187.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":187.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":277.800,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":194.460,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":188.900,"methodology":"fee schedule"}]}]},{"description":"Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double ","code_information":[{"code":"26554","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion of pancreas (eg, cyst, adenoma) ","code_information":[{"code":"480","type":"RC"},{"code":"48120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Omentectomy, epiploectomy, resection of omentum (separate procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"49255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Closure of gastrostomy, surgical ","code_information":[{"code":"43870","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"73222","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":438.470,"maximum":932.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":438.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":497.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":438.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":533.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":932.270,"methodology":"fee schedule"}]}]},{"description":"Burr hole(s); with aspiration of hematoma or cyst, intracerebral ","code_information":[{"code":"367","type":"RC"},{"code":"61156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"329","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":71.890,"maximum":87.430,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":71.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":81.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":71.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":87.430,"methodology":"fee schedule"}]}]},{"description":"Discography, lumbar, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"72295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.620,"maximum":3947.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":170.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":193.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":170.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":207.860,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":103.620,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":123.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2304.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3947.380,"methodology":"fee schedule"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC ","code_information":[{"code":"154","type":"RC"},{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23095.650,"maximum":23095.650,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23095.650,"methodology":"fee schedule"}]}]},{"description":"Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) ","code_information":[{"code":"0442T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiolo ","code_information":[{"code":"37218","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, elbow; complete, minimum of 3 views ","code_information":[{"code":"340","type":"RC"},{"code":"73080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Amputation, arm through humerus; with implant ","code_information":[{"code":"24931","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; ","code_information":[{"code":"63050","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination or diagnosis with semen analysis ","code_information":[{"code":"89260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":63.030,"maximum":139.960,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":63.030,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":137.160,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":139.960,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":134.360,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":137.160,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":139.960,"methodology":"fee schedule"}]}]},{"description":"Exchange transfusion, blood; newborn ","code_information":[{"code":"36450","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"63664","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":25632.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"74160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":392.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":322.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":365.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":322.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":392.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Specific gravity (except urine) ","code_information":[{"code":"303","type":"RC"},{"code":"84315","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.070,"maximum":3.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.610,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.280,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography without contrast, chest (excluding myocardium) ","code_information":[{"code":"618","type":"RC"},{"code":"C8910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":517.790,"maximum":517.790,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance ","code_information":[{"code":"20610","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reinsertion of spinal fixation device ","code_information":[{"code":"22849","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":16000.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":16000.000,"methodology":"case rate"}]}]},{"description":"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL ","code_information":[{"code":"146","type":"RC"},{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":30227.270,"maximum":30227.270,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":30227.270,"methodology":"fee schedule"}]}]},{"description":"Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon ","code_information":[{"code":"26412","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15042.990,"maximum":15042.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15042.990,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, soft tissue neck; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"70491","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":86.020,"maximum":104.620,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":86.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":97.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":86.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":104.620,"methodology":"fee schedule"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"174","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13450.430,"maximum":13450.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13450.430,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; for infection, lavage and drainage ","code_information":[{"code":"29871","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of carpal scaphoid (navicular) fracture; without manipulation ","code_information":[{"code":"25622","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"17271","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling ","code_information":[{"code":"342","type":"RC"},{"code":"78110","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":89.530,"maximum":103.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":89.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":101.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":89.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":103.210,"methodology":"fee schedule"}]}]},{"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":"329","type":"RC"},{"code":"77085","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":19.450,"maximum":23.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.660,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent ","code_information":[{"code":"21485","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Complex dynamic pharyngeal and speech evaluation by cine or video recording ","code_information":[{"code":"321","type":"RC"},{"code":"70371","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.680,"maximum":517.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":155.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":176.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":155.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":188.820,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":90.680,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":120.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Injection procedure for retrograde urethrocystography ","code_information":[{"code":"490","type":"RC"},{"code":"51610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, inner ear ","code_information":[{"code":"362","type":"RC"},{"code":"69949","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation ","code_information":[{"code":"23600","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thawing of cryopreserved; sperm/semen, each aliquot ","code_information":[{"code":"302","type":"RC"},{"code":"89353","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46.530,"maximum":54.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":46.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":54.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":46.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":54.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"67334","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate ","code_information":[{"code":"319","type":"RC"},{"code":"87046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.440,"maximum":11.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.140,"methodology":"fee schedule"}]}]},{"description":"Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver, including analysis, program ","code_information":[{"code":"0988T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Ureteral reflux study (radiopharmaceutical voiding cystogram) ","code_information":[{"code":"341","type":"RC"},{"code":"78740","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":36.830,"maximum":42.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":41.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.450,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC ","code_information":[{"code":"153","type":"RC"},{"code":"320","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18712.880,"maximum":18712.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18712.880,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imagin ","code_information":[{"code":"49327","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Antibody; Yersinia ","code_information":[{"code":"300","type":"RC"},{"code":"86793","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.330,"maximum":15.560,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.510,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.190,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":29389.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":26754.240,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":10695.600,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":26754.240,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":26754.240,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":26754.240,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":19110.170,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":24161.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":27408.230,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":10907.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":24161.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29389.500,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":13237.130,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":10801.490,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":9001.250,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":9001.250,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":10801.490,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":10801.490,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14183.990,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":11013.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14554.800,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":11013.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":10272.010,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":10916.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10695.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":10695.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":10695.600,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":10589.700,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":10589.700,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":10589.700,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14473.460,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":15161.270,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":12495.780,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":15017.270,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":11502.460,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":11013.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13894.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":11013.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":14183.990,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":15884.550,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11119.190,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":10589.700,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14473.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13596.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10367.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":10589.700,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":10589.700,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":10801.490,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12565.900,"maximum":19067.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19067.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14254.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15285.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14745.300,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time ","code_information":[{"code":"320","type":"RC"},{"code":"76000","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":20.720,"maximum":25.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25.200,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion of spermatic cord (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"55520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) ","code_information":[{"code":"66761","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9176.020,"maximum":9176.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9176.020,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed ","code_information":[{"code":"61715","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of pilonidal cyst or sinus; extensive ","code_information":[{"code":"11771","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7334.440,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7041.060,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"168","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7968.240,"maximum":8625.410,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":8625.410,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":7968.240,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22149.660,"maximum":22149.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22149.660,"methodology":"fee schedule"}]}]},{"description":"Intubation, endotracheal, emergency procedure ","code_information":[{"code":"31500","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, nasal bones, complete, minimum of 3 views ","code_information":[{"code":"409","type":"RC"},{"code":"70160","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":41.090,"maximum":49.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":46.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.970,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; subclavian-subclavian ","code_information":[{"code":"35612","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PNEUMOTHORAX WITH CC ","code_information":[{"code":"114","type":"RC"},{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9402.710,"maximum":9402.710,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9402.710,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments ","code_information":[{"code":"63101","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":12326.500,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification ","code_information":[{"code":"619","type":"RC"},{"code":"78473","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Protein, total, by refractometry, any source ","code_information":[{"code":"302","type":"RC"},{"code":"84160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.250,"maximum":6.620,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.170,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.620,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.610,"methodology":"fee schedule"}]}]},{"description":"Albumin; serum, plasma or whole blood ","code_information":[{"code":"311","type":"RC"},{"code":"82040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.950,"maximum":5.840,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.840,"methodology":"fee schedule"}]}]},{"description":"Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) ","code_information":[{"code":"58563","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","median_amount":3580.390,"10th_percentile":3484.330,"90th_percentile":4081.820,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in a ","code_information":[{"code":"19288","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg ","code_information":[{"code":"Q2050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":100.420,"maximum":356.380,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"OpenAccess","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"POS","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"QualifiedHealthPlan","standard_charge_percentage":25.86,"standard_charge_algorithm":"Reimbursement will be 25.86% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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 Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":100.420,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":124.720,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":183.410,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":349.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":145.900,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":356.380,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":122.270,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":342.120,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":349.250,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":356.380,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic a3cid, genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via qua ","code_information":[{"code":"0371U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":404.280,"maximum":625.170,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":437.620,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":429.280,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":437.620,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":625.170,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":437.620,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":437.620,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":404.280,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":625.170,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":437.620,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":425.120,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrod ","code_information":[{"code":"0410T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"309","type":"RC"},{"code":"81271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Melphalan; oral, 2 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J8600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":10.060,"maximum":10.060,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.060,"methodology":"fee schedule"}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR ","code_information":[{"code":"120","type":"RC"},{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":44385.720,"maximum":44385.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":44385.720,"methodology":"fee schedule"}]}]},{"description":"Oncology (ovarian), biochemical assays of 7 proteins (follicle stimulating hormone, human epididymis protein 4, apolipoprotein A-1, transferrin, beta-2 macroglobulin, prea0lbumin, and cancer antigen 1 ","code_information":[{"code":"0375U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":897.000,"maximum":1058.460,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1058.460,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique ","code_information":[{"code":"309","type":"RC"},{"code":"87555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.130,"maximum":31.720,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29.570,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":26.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":31.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26.880,"methodology":"fee schedule"}]}]},{"description":"Fibrinolytic factors and inhibitors; plasminogen, except antigenic assay ","code_information":[{"code":"311","type":"RC"},{"code":"85420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.530,"maximum":7.710,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.710,"methodology":"fee schedule"}]}]},{"description":"Oncology evaluation of 17 DNA biomarkers using droplet digital PCR, cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence ","code_information":[{"code":"0356U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1800.000,"maximum":2124.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1800.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2124.000,"methodology":"fee schedule"}]}]},{"description":"Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluoroscopy and/or ultrasound guidance, when performed; 6 years and older without congenital cardiac anomaly ","code_information":[{"code":"33017","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"111","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7172.830,"maximum":7172.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7172.830,"methodology":"fee schedule"}]}]},{"description":"Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) ","code_information":[{"code":"490","type":"RC"},{"code":"55812","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"323","type":"RC"},{"code":"73202","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":269.830,"maximum":328.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":269.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":306.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":269.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":328.160,"methodology":"fee schedule"}]}]},{"description":"Immune globulin (IgIV), human, for intravenous use ","code_information":[{"code":"343","type":"RC"},{"code":"90283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":203.280,"maximum":203.280,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":203.280,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm ","code_information":[{"code":"17264","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1004.710,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1025.640,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":1046.570,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1004.710,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":1025.640,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":1046.570,"methodology":"fee schedule"}]}]},{"description":"Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir ","code_information":[{"code":"367","type":"RC"},{"code":"62360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITH MCC ","code_information":[{"code":"172","type":"RC"},{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":38674.150,"maximum":38674.150,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":38674.150,"methodology":"fee schedule"}]}]},{"description":"Valvuloplasty, tricuspid valve; with ring insertion ","code_information":[{"code":"33464","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) ","code_information":[{"code":"28262","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) ","code_information":[{"code":"314","type":"RC"},{"code":"81357","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.250,"maximum":228.030,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":228.030,"methodology":"fee schedule"}]}]},{"description":"Antineutrophil cytoplasmic antibody (ANCA); screen, each antibody ","code_information":[{"code":"310","type":"RC"},{"code":"86036","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.050,"maximum":14.220,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.220,"methodology":"fee schedule"}]}]},{"description":"Closure of rectovesical fistula; with colostomy ","code_information":[{"code":"45805","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC ","code_information":[{"code":"212","type":"RC"},{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12788.880,"maximum":12788.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12788.880,"methodology":"fee schedule"}]}]},{"description":"Injection, furosemide, 1 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.040,"maximum":0.040,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.040,"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Biopsy, soft tissue of neck or thorax ","code_information":[{"code":"21550","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITH CC ","code_information":[{"code":"201","type":"RC"},{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10896.190,"maximum":10896.190,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10896.190,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14451.310,"maximum":14451.310,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14451.310,"methodology":"fee schedule"}]}]},{"description":"INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMODILUTION, INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; WITH CARDIAC OUTPUT MEASUREMENT (SEPARATE PROCEDURE) ","code_information":[{"code":"481","type":"RC"},{"code":"93561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) ","code_information":[{"code":"31235","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"137","type":"RC"},{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26938.770,"maximum":26938.770,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26938.770,"methodology":"fee schedule"}]}]},{"description":"Goniotomy ","code_information":[{"code":"65820","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, w ","code_information":[{"code":"81001","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2.960,"maximum":3.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.170,"methodology":"fee schedule"}]}]},{"description":"Amnio burgeon membrane and hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"360","type":"RC"},{"code":"49451","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage ","code_information":[{"code":"38207","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":" Continuous Cycling Peritoneal Dialysis - Outpatient or Home - Home Equipment  ","code_information":[{"code":"853","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":258.000,"maximum":1856.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1526.040,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1731.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1526.040,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1856.270,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":1790.720,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":258.000,"methodology":"case rate"}]}]},{"description":"Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) ( ","code_information":[{"code":"790","type":"RC"},{"code":"91013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Drainage of scrotal wall abscess ","code_information":[{"code":"362","type":"RC"},{"code":"55100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Catheterization with removal of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate ","code_information":[{"code":"362","type":"RC"},{"code":"53866","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOCRINE DISORDERS WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13300.730,"maximum":13300.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13300.730,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) ","code_information":[{"code":"43775","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nitroblue tetrazolium dye test (NTD) ","code_information":[{"code":"86384","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.650,"maximum":20.410,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":13.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":14.020,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":13.880,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":19.820,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":13.880,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":20.410,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":13.200,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":16.330,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":13.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":13.750,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":11.650,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":20.410,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":13.880,"methodology":"fee schedule"}]}]},{"description":"Angiography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"349","type":"RC"},{"code":"75710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"173","type":"RC"},{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":44075.610,"maximum":44075.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":44075.610,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC ","code_information":[{"code":"154","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7196.360,"maximum":7196.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7196.360,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal ","code_information":[{"code":"481","type":"RC"},{"code":"60650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural ","code_information":[{"code":"361","type":"RC"},{"code":"61615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Culture, bacterial; with isolation and presumptive identification of each isolate, urine ","code_information":[{"code":"300","type":"RC"},{"code":"87088","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.560,"maximum":9.550,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8.900,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.550,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.090,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of a ","code_information":[{"code":"33965","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8525.870,"maximum":8525.870,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8525.870,"methodology":"fee schedule"}]}]},{"description":"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY ","code_information":[{"code":"209","type":"RC"},{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8714.070,"maximum":8714.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8714.070,"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":"490","type":"RC"},{"code":"C7507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy ","code_information":[{"code":"43262","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments ","code_information":[{"code":"22818","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, younger than 12 years of age ","code_information":[{"code":"31553","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC ","code_information":[{"code":"219","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7196.360,"maximum":7196.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7196.360,"methodology":"fee schedule"}]}]},{"description":"Triamcinolone a inj prs-f ","code_information":[{"code":"1253","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":23.760,"maximum":36.740,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":24.740,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":25.720,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":24.980,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":24.490,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25.720,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":25.720,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":23.760,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":24.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":24.740,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":24.490,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":24.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":24.490,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":36.740,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":25.720,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":24.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":24.490,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":24.980,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, neck or thorax ","code_information":[{"code":"21899","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15019.470,"maximum":15019.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15019.470,"methodology":"fee schedule"}]}]},{"description":"Tracheostoma revision; complex, with flap rotation ","code_information":[{"code":"31614","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16660.510,"maximum":16660.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16660.510,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and rad ","code_information":[{"code":"37246","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"127","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6907.640,"maximum":6907.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6907.640,"methodology":"fee schedule"}]}]},{"description":"Coagulation/fibrinolysis assay, whole blood (eg, viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day ","code_information":[{"code":"305","type":"RC"},{"code":"85396","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.600,"maximum":21.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.890,"methodology":"fee schedule"}]}]},{"description":"Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75741","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":78.820,"maximum":95.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":78.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":89.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":78.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":95.860,"methodology":"fee schedule"}]}]},{"description":"Exposure of prostate, any approach, for insertion of radioactive substance; ","code_information":[{"code":"481","type":"RC"},{"code":"55860","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":25384.100,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20868.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23672.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20868.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25384.100,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":24487.700,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11330.000,"methodology":"case rate"}]}]},{"description":"PERCUT KYPHOPLASTY ADD-ON ","code_information":[{"code":"22525","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":1496.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) ","code_information":[{"code":"341","type":"RC"},{"code":"71551","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":932.270,"maximum":932.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":932.270,"methodology":"fee schedule"}]}]},{"description":"INSERTION OF INFUSION PUMP ","code_information":[{"code":"36530","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Gastroesophageal reflux study ","code_information":[{"code":"349","type":"RC"},{"code":"78262","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":42.510,"maximum":49.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":48.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.000,"methodology":"fee schedule"}]}]},{"description":"Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair ","code_information":[{"code":"27524","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"Nephelometry, each analyte not elsewhere specified ","code_information":[{"code":"310","type":"RC"},{"code":"83883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.600,"maximum":16.050,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.050,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":31605.970,"maximum":31605.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":31605.970,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps ","code_information":[{"code":"31032","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Open treatment of clavicular fracture, includes internal fixation, when performed ","code_information":[{"code":"23515","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"MR safety determination by a physician or other qualified health care professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examinatio ","code_information":[{"code":"619","type":"RC"},{"code":"76016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":198.110,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":198.110,"methodology":"fee schedule"}]}]},{"description":"Lymphangiotomy or other operations on lymphatic channels ","code_information":[{"code":"360","type":"RC"},{"code":"38308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC One Day Stay","code_information":[{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"SPLENIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15174.160,"maximum":15174.160,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15174.160,"methodology":"fee schedule"}]}]},{"description":"Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep-disordered breathing, flexible, diagnostic ","code_information":[{"code":"42975","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"212","type":"RC"},{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10022.200,"maximum":10022.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10022.200,"methodology":"fee schedule"}]}]},{"description":"BREAST RECONSTRUCTION WITH OTHER TECHNIQUE ","code_information":[{"code":"19366","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11468.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu ","code_information":[{"code":"J9215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"OpenAccess","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"POS","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"QualifiedHealthPlan","standard_charge_percentage":25.86,"standard_charge_algorithm":"Reimbursement will be 25.86% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervisio ","code_information":[{"code":"490","type":"RC"},{"code":"50431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT Pediatric","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":335288.250,"maximum":469390.740,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":469390.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":469390.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":469390.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":469390.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":335288.250,"methodology":"fee schedule"}]}]},{"description":"SEIZURES WITHOUT MCC ","code_information":[{"code":"101","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8000.480,"maximum":8000.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8000.480,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"211","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12491.610,"maximum":12491.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12491.610,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC ","code_information":[{"code":"169","type":"RC"},{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8844.530,"maximum":8844.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8844.530,"methodology":"fee schedule"}]}]},{"description":"Silica ","code_information":[{"code":"314","type":"RC"},{"code":"84285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.210,"maximum":29.750,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":29.750,"methodology":"fee schedule"}]}]},{"description":"Carbon dioxide (bicarbonate) ","code_information":[{"code":"310","type":"RC"},{"code":"82374","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.880,"maximum":5.760,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.760,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) ","code_information":[{"code":"73221","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":298.560,"maximum":298.560,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":298.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":298.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":298.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":298.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":298.560,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC ","code_information":[{"code":"137","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17098.220,"maximum":17098.220,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17098.220,"methodology":"fee schedule"}]}]},{"description":"Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) ","code_information":[{"code":"27303","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"MR safety determination by a physician or other qualified health care professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examinatio ","code_information":[{"code":"329","type":"RC"},{"code":"76016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":99.880,"maximum":121.470,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":99.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":113.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":99.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":121.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"IDH1 (isocitrate dehydrogenase 1 ºNADP+», soluble) (eg, glioma), common variants (eg, R132H, R132C) ","code_information":[{"code":"305","type":"RC"},{"code":"81120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":180.690,"maximum":228.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":228.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":193.250,"methodology":"fee schedule"}]}]},{"description":"PENIS PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11554.880,"maximum":11554.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11554.880,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) ","code_information":[{"code":"36012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of tonsil tags ","code_information":[{"code":"42860","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report ","code_information":[{"code":"0612T","type":"CPT"},{"code":"342","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":63.590,"maximum":63.590,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":63.590,"methodology":"fee schedule"}]}]},{"description":"Prostaglandin, each ","code_information":[{"code":"306","type":"RC"},{"code":"84150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.050,"maximum":49.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":39.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":45.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":39.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.950,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":41.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":49.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":41.770,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of femoral fracture, proximal end, neck; without manipulation ","code_information":[{"code":"27230","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Level 1 Endovascular Proc ","code_information":[{"code":"05191","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2919.590,"maximum":2919.590,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2919.590,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging with contrast, breast; bilateral ","code_information":[{"code":"616","type":"RC"},{"code":"C8906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":828.270,"maximum":828.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Antibody; cytomegalovirus (CMV), IgM ","code_information":[{"code":"319","type":"RC"},{"code":"86645","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.850,"maximum":19.880,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.880,"methodology":"fee schedule"}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC One Day Stay","code_information":[{"code":"266","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PROSTATECTOMY WITH CC ","code_information":[{"code":"210","type":"RC"},{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14036.410,"maximum":14036.410,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14036.410,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"},{"code":"172","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7242.700,"maximum":7242.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7242.700,"methodology":"fee schedule"}]}]},{"description":"Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) ","code_information":[{"code":"30465","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) ","code_information":[{"code":"64520","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative ","code_information":[{"code":"352","type":"RC"},{"code":"78472","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring ","code_information":[{"code":"481","type":"RC"},{"code":"61533","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"618","type":"RC"},{"code":"72127","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Repair, acquired or traumatic arteriovenous fistula; head and neck ","code_information":[{"code":"35188","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with esophagomyotomy (Heller type) ","code_information":[{"code":"32665","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"}]}]},{"description":"Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and a ","code_information":[{"code":"361","type":"RC"},{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":26780.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13647.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15481.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13647.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16600.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":16014.100,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26780.000,"methodology":"case rate"}]}]},{"description":"New Technology - Level 45 ","code_information":[{"code":"01582","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":57296.490,"maximum":57296.490,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":57296.490,"methodology":"fee schedule"}]}]},{"description":"Sevelamer hydrochloride (renagel or therapeutically equivalent), oral, 20 mg (for esrd on dialysis) ","code_information":[{"code":"892","type":"RC"},{"code":"J0603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.430,"maximum":0.430,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.430,"methodology":"fee schedule"}]}]},{"description":"Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy ","code_information":[{"code":"362","type":"RC"},{"code":"67010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) ","code_information":[{"code":"81342","type":"CPT"},{"code":"818180","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":181.350,"maximum":350.750,"gross_charge":961.75,"discounted_cash":961.75,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":181.350,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":203.520,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":181.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":181.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":181.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":181.350,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":192.650,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":207.550,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":187.150,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":211.580,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":350.750,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":205.530,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":275.220,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":211.580,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":211.580,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":195.450,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":241.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":203.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":203.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":203.520,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":183.480,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":302.250,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":211.580,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":205.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":205.530,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"806","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2396.740,"maximum":2594.400,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":2594.400,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2396.740,"methodology":"fee schedule"}]}]},{"description":"Excision or fulguration; urethral prolapse ","code_information":[{"code":"480","type":"RC"},{"code":"53275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"027","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19551.220,"maximum":19551.220,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19551.220,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, temporal bone, middle fossa approach ","code_information":[{"code":"499","type":"RC"},{"code":"69979","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care ","code_information":[{"code":"59410","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"0796T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"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), ea ","code_information":[{"code":"31651","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched ","code_information":[{"code":"0048U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2919.600,"maximum":3445.130,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3445.130,"methodology":"fee schedule"}]}]},{"description":"Catheterization with bronchial brush biopsy ","code_information":[{"code":"31717","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5994.450,"maximum":5994.450,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5994.450,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) ","code_information":[{"code":"329","type":"RC"},{"code":"70336","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":90.540,"maximum":110.120,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":90.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":102.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":90.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":110.120,"methodology":"fee schedule"}]}]},{"description":"Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus) ","code_information":[{"code":"359","type":"RC"},{"code":"74283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Injection, pentazocine, 30 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J3070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":58.890,"maximum":58.890,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":58.890,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm ","code_information":[{"code":"11626","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncoprotein; HER-2/neu ","code_information":[{"code":"83950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.150,"maximum":112.120,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":57.970,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":65.050,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":57.970,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":57.970,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":57.970,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":57.970,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":67.630,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":66.340,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":67.630,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":112.120,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":96.610,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":67.630,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":67.630,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":62.480,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":77.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":65.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":65.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":65.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":55.150,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":96.610,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":67.630,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":65.700,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHE ","code_information":[{"code":"041","type":"MS-DRG"},{"code":"160","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":17240.080,"maximum":17240.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17240.080,"methodology":"fee schedule"}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6342.330,"maximum":6342.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6342.330,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, rectum ","code_information":[{"code":"45499","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14369.190,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5690.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13794.420,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"}]}]},{"description":"Aminolevulinic acid, delta (ALA) ","code_information":[{"code":"301","type":"RC"},{"code":"82135","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.380,"maximum":19.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.450,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.450,"methodology":"fee schedule"}]}]},{"description":"Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) ","code_information":[{"code":"38770","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Removal of sub-scalp implanted electrode array, receiver, and telemetry unit for continuous bilateral electroencephalography monitoring system, including imaging guidance ","code_information":[{"code":"0958T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, nose ","code_information":[{"code":"30999","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, intercarpal or carpometacarpal joints; suspension, including transfer or transplant of tendon, with interposition, when performed ","code_information":[{"code":"25448","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14443.460,"maximum":14443.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14443.460,"methodology":"fee schedule"}]}]},{"description":"Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen (eg, bile study for crystals or afferent loop culture) ","code_information":[{"code":"43756","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"137","type":"RC"},{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9903.860,"maximum":9903.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9903.860,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14466.990,"maximum":14466.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14466.990,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"614","type":"RC"},{"code":"73220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":828.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Surgery of intracranial arteriovenous malformation; supratentorial, complex ","code_information":[{"code":"481","type":"RC"},{"code":"61682","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Marsupialization of urethral diverticulum, male or female ","code_information":[{"code":"53240","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage of penis, deep ","code_information":[{"code":"54015","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach ","code_information":[{"code":"0545T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Anti-phosphatidylserine (phospholipid) antibody ","code_information":[{"code":"86148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.760,"maximum":27.970,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":16.550,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":16.390,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":27.970,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":16.390,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":24.110,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":15.590,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":19.280,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":13.760,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":24.110,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":16.390,"methodology":"fee schedule"}]}]},{"description":"Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation and peri-operative interrogation and programming; complete system (incl ","code_information":[{"code":"499","type":"RC"},{"code":"C9750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (Merkel cell-carcinoma), detection of antibodies to the Merkel cell polyoma virus capsid protein (VP1), serum, reported as positive or negative ","code_information":[{"code":"0059U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":301.970,"maximum":381.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":301.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":355.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":301.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":355.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":322.960,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":381.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":322.960,"methodology":"fee schedule"}]}]},{"description":"Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed ","code_information":[{"code":"28615","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT ","code_information":[{"code":"100","type":"RC"},{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15929.100,"maximum":15929.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15929.100,"methodology":"fee schedule"}]}]},{"description":"Fluciclovine f-18 ","code_information":[{"code":"9052","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":312.600,"maximum":483.400,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":325.490,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":331.940,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":338.380,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":328.720,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":322.270,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":338.380,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":338.380,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":312.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":325.490,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":325.490,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":325.490,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":322.270,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":322.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":322.270,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":483.400,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":338.380,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":322.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":328.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":322.270,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":328.720,"methodology":"fee schedule"}]}]},{"description":"1-stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap ","code_information":[{"code":"369","type":"RC"},{"code":"54328","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s) ","code_information":[{"code":"29881","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) ","code_information":[{"code":"319","type":"RC"},{"code":"83020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.870,"maximum":15.190,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.870,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.190,"methodology":"fee schedule"}]}]},{"description":"Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3 ºplatelet glycoprotein IIIa», antigen CD61 ºGPIIIa») (eg, neonatal alloimmune thrombocytopenia ºNAIT», post-transfusion purpura), g ","code_information":[{"code":"303","type":"RC"},{"code":"81105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":114.280,"maximum":144.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":114.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":134.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":114.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":134.440,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":122.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":144.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":122.220,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, appendix ","code_information":[{"code":"361","type":"RC"},{"code":"44979","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"58291","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification ","code_information":[{"code":"319","type":"RC"},{"code":"87492","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":53.470,"maximum":63.090,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":53.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":63.090,"methodology":"fee schedule"}]}]},{"description":"MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALI ","code_information":[{"code":"3432","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5466.850,"maximum":8200.280,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":5466.850,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5576.190,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":8200.280,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":5466.850,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":5466.850,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":5466.850,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) ","code_information":[{"code":"29883","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Division of sternocleidomastoid for torticollis, open operation; with cast application ","code_information":[{"code":"21725","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1769.330,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1806.190,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":1843.050,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1769.330,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":1806.190,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":1843.050,"methodology":"fee schedule"}]}]},{"description":"Drainage of abscess; parotid, simple ","code_information":[{"code":"42300","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail ","code_information":[{"code":"312","type":"RC"},{"code":"87101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.710,"maximum":9.100,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.710,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.100,"methodology":"fee schedule"}]}]},{"description":"Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access ","code_information":[{"code":"36581","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10300.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4949.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4363.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5307.440,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":5120.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10300.000,"methodology":"case rate"}]}]},{"description":"Open treatment of calcaneal fracture, includes internal fixation, when performed; ","code_information":[{"code":"28415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C ","code_information":[{"code":"148","type":"RC"},{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Unlisted laparoscopy procedure, uterus ","code_information":[{"code":"362","type":"RC"},{"code":"58578","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Thoracotomy; with open intrapleural pneumonolysis ","code_information":[{"code":"32124","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":" Anesthesia Incident to Other DX Services  ","code_information":[{"code":"372","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Wedge resection or bisection of ovary, unilateral or bilateral ","code_information":[{"code":"360","type":"RC"},{"code":"58920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Suture and/or ligation of thoracic duct; cervical approach ","code_information":[{"code":"38380","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES ","code_information":[{"code":"7243","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9280.930,"maximum":13921.400,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":9280.930,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":9466.550,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":13921.400,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":9280.930,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":9280.930,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":9280.930,"methodology":"fee schedule"}]}]},{"description":"Hepatitis Be antibody (HBeAb) ","code_information":[{"code":"305","type":"RC"},{"code":"86707","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.820,"maximum":13.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.730,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.570,"methodology":"fee schedule"}]}]},{"description":"Therapeutic apheresis; for red blood cells ","code_information":[{"code":"36512","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Venography, caval, inferior, with serialography, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"75825","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency (List separately in addition to code for primary procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"60661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers ","code_information":[{"code":"37291","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; cryptosporidium ","code_information":[{"code":"314","type":"RC"},{"code":"87272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.980,"maximum":14.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"}]}]},{"description":"Transposition and/or reimplantation; carotid to subclavian artery ","code_information":[{"code":"35695","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12799.560,"maximum":12799.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12799.560,"methodology":"fee schedule"}]}]},{"description":"Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic alg ","code_information":[{"code":"301","type":"RC"},{"code":"81596","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":67.500,"maximum":85.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":67.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":79.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":67.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":79.410,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":72.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":85.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":72.190,"methodology":"fee schedule"}]}]},{"description":"Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed ","code_information":[{"code":"43889","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Lymphatics and lymph nodes imaging ","code_information":[{"code":"323","type":"RC"},{"code":"78195","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":359.950,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":597.860,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":359.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine (liver allograft rejection), quantitative donor-derived cell-free DNA (cfDNA) by whole genome nextgeneration sequencing, ","code_information":[{"code":"0576U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3029.400,"maximum":3823.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3029.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3564.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3029.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3240.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3823.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3240.000,"methodology":"fee schedule"}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY ","code_information":[{"code":"172","type":"RC"},{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22784.130,"maximum":22784.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22784.130,"methodology":"fee schedule"}]}]},{"description":"Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Everolimus ","code_information":[{"code":"310","type":"RC"},{"code":"80169","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.730,"maximum":16.200,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.200,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST PROCEDURES WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"164","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19559.070,"maximum":19559.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19559.070,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical therapy, by intracavitary administration ","code_information":[{"code":"404","type":"RC"},{"code":"79200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":264.470,"maximum":264.470,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":264.470,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10138.400,"maximum":10138.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10138.400,"methodology":"fee schedule"}]}]},{"description":"Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure ","code_information":[{"code":"11005","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, ","code_information":[{"code":"304","type":"RC"},{"code":"81448","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":546.880,"maximum":690.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":546.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":643.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":546.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":643.390,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":584.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":690.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":584.900,"methodology":"fee schedule"}]}]},{"description":"Manipulation, wrist, under anesthesia ","code_information":[{"code":"25259","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Mammary ductogram or galactogram, single duct, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"77053","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Antibody; Epstein-Barr (EB) virus, early antigen (EA) ","code_information":[{"code":"306","type":"RC"},{"code":"86663","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.270,"maximum":15.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.430,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.120,"methodology":"fee schedule"}]}]},{"description":"Covid-19 convalescent pla ","code_information":[{"code":"09540","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":659.630,"maximum":659.630,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":659.630,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplast ","code_information":[{"code":"36907","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"112","type":"RC"},{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6477.780,"maximum":6477.780,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6477.780,"methodology":"fee schedule"}]}]},{"description":"Percutaneous pulmonary artery revascularization by stent placement, each additional vessel or separate lesion, normal or abnormal connections (List separately in addition to code for primary procedure ","code_information":[{"code":"33904","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"499","type":"RC"},{"code":"58571","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":24184.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":18137.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Craniotomy for craniosynostosis; frontal or parietal bone flap ","code_information":[{"code":"369","type":"RC"},{"code":"61556","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Borrelia burgdorferi, antibody detection of 24 recombinant protein groups, by immunoassay, IgG ","code_information":[{"code":"0580U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16.090,"maximum":20.310,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.930,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.210,"methodology":"fee schedule"}]}]},{"description":"Copy number (eg, intellectual disability, dysmorphology), sequence analysis ","code_information":[{"code":"0156U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1626.900,"maximum":2053.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1626.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1914.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1626.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1914.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1740.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2053.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1740.000,"methodology":"fee schedule"}]}]},{"description":"Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal ","code_information":[{"code":"62294","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) ","code_information":[{"code":"27122","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13952.290,"maximum":13952.290,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13952.290,"methodology":"fee schedule"}]}]},{"description":"Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon ","code_information":[{"code":"25310","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Testosterone; bioavailable, direct measurement (eg, differential precipitation) ","code_information":[{"code":"84410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":43.910,"maximum":89.280,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":46.150,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":51.790,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":46.150,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":46.150,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":46.150,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":46.150,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":52.820,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":52.310,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":89.280,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":52.310,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":76.920,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":49.740,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":61.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":51.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":51.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":51.790,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":43.910,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":76.920,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":52.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":52.310,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"21932","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed ","code_information":[{"code":"340","type":"RC"},{"code":"77407","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":310.320,"maximum":310.320,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.320,"methodology":"fee schedule"}]}]},{"description":"Release, intrinsic muscles of hand, each muscle ","code_information":[{"code":"26593","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7967.210,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"}]}]},{"description":"Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor ","code_information":[{"code":"43117","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of neurofibroma or neurolemmoma; extensive (including malignant type) ","code_information":[{"code":"490","type":"RC"},{"code":"64792","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, fomepizole, 15 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J1451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":13.820,"maximum":13.820,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.820,"methodology":"fee schedule"}]}]},{"description":"Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators ","code_information":[{"code":"324","type":"RC"},{"code":"77615","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":1368.570,"maximum":1664.390,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1368.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1552.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1368.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1664.390,"methodology":"fee schedule"}]}]},{"description":"Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration ","code_information":[{"code":"499","type":"RC"},{"code":"61580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA ","code_information":[{"code":"151","type":"RC"},{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28391.610,"maximum":28391.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28391.610,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC ","code_information":[{"code":"164","type":"RC"},{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6060.030,"maximum":6060.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6060.030,"methodology":"fee schedule"}]}]},{"description":"Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, ","code_information":[{"code":"480","type":"RC"},{"code":"58952","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views ","code_information":[{"code":"321","type":"RC"},{"code":"73502","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":51.690,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":68.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":68.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":83.230,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":57.960,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":51.690,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Ostectomy, complete excision; first metatarsal head ","code_information":[{"code":"28111","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter ","code_information":[{"code":"400","type":"RC"},{"code":"76510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":152.100,"maximum":152.100,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":152.100,"methodology":"fee schedule"}]}]},{"description":"Epididymectomy; bilateral ","code_information":[{"code":"54861","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, tendon, extensor, foot; primary or secondary, each tendon ","code_information":[{"code":"28208","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5633.020,"maximum":5633.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5633.020,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed ","code_information":[{"code":"45393","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"202","type":"RC"},{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8401.120,"maximum":15285.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8401.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14254.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15285.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14745.300,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis ","code_information":[{"code":"0308T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":25632.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":4135.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3435.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":4096.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25200.000,"methodology":"case rate"}]}]},{"description":"ENDOBRONCHIAL US ADD-ON ","code_information":[{"code":"31620","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) ","code_information":[{"code":"340","type":"RC"},{"code":"78016","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.510,"maximum":50.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":49.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.150,"methodology":"fee schedule"}]}]},{"description":"Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each ","code_information":[{"code":"28455","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fine needle aspiration of orbital contents ","code_information":[{"code":"362","type":"RC"},{"code":"67415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Potassium; serum, plasma or whole blood ","code_information":[{"code":"306","type":"RC"},{"code":"84132","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.450,"maximum":5.620,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.620,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.760,"methodology":"fee schedule"}]}]},{"description":"Venography, renal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"610","type":"RC"},{"code":"75833","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"Renal allotransplantation, implantation of graft; without recipient nephrectomy ","code_information":[{"code":"50360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coh ","code_information":[{"code":"369","type":"RC"},{"code":"C7569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Ureteral reflux study (radiopharmaceutical voiding cystogram) ","code_information":[{"code":"349","type":"RC"},{"code":"78740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":311.150,"maximum":848.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":311.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":352.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":311.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":358.690,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC ","code_information":[{"code":"144","type":"RC"},{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8916.530,"maximum":8916.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8916.530,"methodology":"fee schedule"}]}]},{"description":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any ","code_information":[{"code":"64492","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC ","code_information":[{"code":"201","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14362.200,"maximum":14362.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14362.200,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia ","code_information":[{"code":"26675","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"SALIVARY GLAND PROCEDURES ","code_information":[{"code":"122","type":"RC"},{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10375.080,"maximum":10375.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10375.080,"methodology":"fee schedule"}]}]},{"description":"Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma ","code_information":[{"code":"0251U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16.150,"maximum":20.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.270,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm ","code_information":[{"code":"12034","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"67340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13563.070,"maximum":13563.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13563.070,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic ","code_information":[{"code":"320","type":"RC"},{"code":"72157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":371.280,"maximum":541.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":444.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":504.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":444.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":541.010,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":513.990,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":371.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, subsequent, same hospital stay ","code_information":[{"code":"31646","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"AFF2 (ALF transcription elongation factor 2 ºFMR2») (eg, fragile X intellectual disability 2 ºFRAXE») gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"314","type":"RC"},{"code":"81171","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":137.000,"maximum":161.660,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas ","code_information":[{"code":"351","type":"RC"},{"code":"78801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Removal of subdeltoid calcareous deposits, open ","code_information":[{"code":"23000","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Miro3d fibers, per milligram ","code_information":[{"code":"343","type":"RC"},{"code":"A2030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":11.760,"maximum":11.760,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.760,"methodology":"fee schedule"}]}]},{"description":"Plastic operation on penis for epispadias distal to external sphincter; with incontinence ","code_information":[{"code":"481","type":"RC"},{"code":"54385","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, femur or knee ","code_information":[{"code":"27365","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCED ","code_information":[{"code":"11101","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"481","type":"RC"},{"code":"61645","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITHOUT VAGOTOMY ","code_information":[{"code":"43850","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7411.200,"maximum":7411.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Cerebrospinal fluid leakage detection and localization ","code_information":[{"code":"342","type":"RC"},{"code":"78650","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":313.390,"maximum":361.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":313.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":355.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":313.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":361.270,"methodology":"fee schedule"}]}]},{"description":"Glucagon ","code_information":[{"code":"312","type":"RC"},{"code":"82943","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.290,"maximum":16.860,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.860,"methodology":"fee schedule"}]}]},{"description":"Biopsy, muscle; deep ","code_information":[{"code":"20205","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, remestemcel-l-rknd, per therapeutic dose ","code_information":[{"code":"891","type":"RC"},{"code":"J3402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":433588.390,"maximum":433588.390,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":433588.390,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material ","code_information":[{"code":"342","type":"RC"},{"code":"72128","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Manipulation, wrist, under anesthesia ","code_information":[{"code":"25259","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Acylcarnitines; quantitative, each specimen ","code_information":[{"code":"312","type":"RC"},{"code":"82017","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.870,"maximum":19.910,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.910,"methodology":"fee schedule"}]}]},{"description":"CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) ","code_information":[{"code":"301","type":"RC"},{"code":"81190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":173.160,"maximum":218.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":218.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"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":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or ","code_information":[{"code":"63035","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"27619","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Debridement, bone including epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed, first 20 sq cm or less with manual preparation and insertion of deep (e.g., subfacial) drug-deli ","code_information":[{"code":"481","type":"RC"},{"code":"C7500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7417.150,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability ","code_information":[{"code":"307","type":"RC"},{"code":"81463","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.860,"maximum":1587.470,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1257.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1479.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1257.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1479.840,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1345.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1587.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1345.310,"methodology":"fee schedule"}]}]},{"description":"Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graf ","code_information":[{"code":"26123","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair of laceration; application of tissue glue, wounds of cornea and/or sclera ","code_information":[{"code":"65286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":5364.400,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":5257.110,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":5364.400,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":5149.820,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":5257.110,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":5364.400,"methodology":"fee schedule"}]}]},{"description":"Insertion of pacemaker pulse generator only; with existing dual leads ","code_information":[{"code":"33213","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration) ","code_information":[{"code":"69632","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vestibular device implantation, unilateral ","code_information":[{"code":"0725T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent ","code_information":[{"code":"21485","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"22900","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT Pediatric","code_information":[{"code":"014","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":188729.100,"maximum":264213.530,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":264213.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":264213.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":264213.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":264213.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":188729.100,"methodology":"fee schedule"}]}]},{"description":"Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score ","code_information":[{"code":"309","type":"RC"},{"code":"81490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":786.010,"maximum":991.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":786.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":924.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":786.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":924.720,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":840.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":991.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":840.650,"methodology":"fee schedule"}]}]},{"description":"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"151","type":"RC"},{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19097.130,"maximum":19097.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19097.130,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with removal of two lobes (bilobectomy) ","code_information":[{"code":"32670","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Biopsy of intestine by capsule, tube, peroral (1 or more specimens) ","code_information":[{"code":"44100","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23095.650,"maximum":23095.650,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23095.650,"methodology":"fee schedule"}]}]},{"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) ","code_information":[{"code":"341","type":"RC"},{"code":"77470","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.600,"maximum":682.600,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft ","code_information":[{"code":"24342","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views ","code_information":[{"code":"322","type":"RC"},{"code":"72120","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":14.550,"maximum":17.690,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.690,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12093.820,"maximum":12093.820,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12093.820,"methodology":"fee schedule"}]}]},{"description":"Right ventricular resection for infundibular stenosis, with or without commissurotomy ","code_information":[{"code":"33476","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus ","code_information":[{"code":"481","type":"RC"},{"code":"64680","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (ie, external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma ","code_information":[{"code":"15778","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Rare diseases, whole genome sequence analysis, incl small sequence changes, copy number variants, deletions, duplications, mobile element insertions, UPD, inversions, aneuploidy, mitochondrial genome ","code_information":[{"code":"0335U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4885.000,"maximum":6165.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4885.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5747.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4885.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5747.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5224.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6165.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5224.600,"methodology":"fee schedule"}]}]},{"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":"0260U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1181.400,"maximum":1490.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1181.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1389.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1181.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1389.880,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1263.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1490.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1263.530,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging guidance for, and monitoring of, parenchymal tissue ablation ","code_information":[{"code":"322","type":"RC"},{"code":"77022","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":236.480,"maximum":414.480,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":414.480,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":236.480,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm ","code_information":[{"code":"12047","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Dehydroepiandrosterone (DHEA) ","code_information":[{"code":"300","type":"RC"},{"code":"82626","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.630,"maximum":29.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":27.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27.800,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":29.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.270,"methodology":"fee schedule"}]}]},{"description":"Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J7674","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.090,"maximum":4.090,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.090,"methodology":"fee schedule"}]}]},{"description":"B-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology ","code_information":[{"code":"0459U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":260.500,"maximum":307.390,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":260.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":307.390,"methodology":"fee schedule"}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16826.610,"maximum":16826.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16826.610,"methodology":"fee schedule"}]}]},{"description":"Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system ","code_information":[{"code":"33237","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3850.000,"maximum":23762.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":10298.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":23762.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5989.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":3850.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":3850.000,"methodology":"case rate"}]}]},{"description":"Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed ","code_information":[{"code":"481","type":"RC"},{"code":"93452","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":14420.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7786.250,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8832.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7786.250,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8977.370,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":10077.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":7557.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":10077.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10077.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":9136.640,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14420.000,"methodology":"case rate"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22568.120,"maximum":22568.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22568.120,"methodology":"fee schedule"}]}]},{"description":"Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas ","code_information":[{"code":"0420T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7284.450,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Injection, teniposide, 50 mg ","code_information":[{"code":"Q2017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"OpenAccess","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"POS","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"QualifiedHealthPlan","standard_charge_percentage":25.86,"standard_charge_algorithm":"Reimbursement will be 25.86% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D190Z9","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3296.000,"maximum":3296.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3296.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique ","code_information":[{"code":"314","type":"RC"},{"code":"87490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.750,"maximum":26.840,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.840,"methodology":"fee schedule"}]}]},{"description":"Antibody; Leishmania ","code_information":[{"code":"310","type":"RC"},{"code":"86717","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.250,"maximum":14.460,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.460,"methodology":"fee schedule"}]}]},{"description":"Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; ","code_information":[{"code":"58957","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8770.160,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, cervical; 4 or 5 views ","code_information":[{"code":"400","type":"RC"},{"code":"72050","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":17.630,"maximum":21.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.440,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses ","code_information":[{"code":"349","type":"RC"},{"code":"76815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (eg, Swanson type cavus foot procedure) ","code_information":[{"code":"28309","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4810.360,"maximum":4810.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4810.360,"methodology":"fee schedule"}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13563.070,"maximum":13563.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13563.070,"methodology":"fee schedule"}]}]},{"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"}],"standard_charges":[{"setting":"outpatient","minimum":499.670,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":510.080,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":520.490,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":499.670,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":510.080,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":520.490,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10936.110,"maximum":10936.110,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10936.110,"methodology":"fee schedule"}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16684.040,"maximum":16684.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16684.040,"methodology":"fee schedule"}]}]},{"description":"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19097.130,"maximum":19097.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19097.130,"methodology":"fee schedule"}]}]},{"description":"Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age ","code_information":[{"code":"31551","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; partial nephrectomy ","code_information":[{"code":"490","type":"RC"},{"code":"50543","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmon ","code_information":[{"code":"32856","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or destruction, open, intra-abdominal (ie, peritoneal, mesenteric, retroperitoneal), primary or secondary tumor(s) or cyst(s), sum of the maximum length of tumor(s) or cyst(s); 5.1 to 10 cm ","code_information":[{"code":"49187","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment ","code_information":[{"code":"22328","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision o ","code_information":[{"code":"50323","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12093.820,"maximum":12093.820,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12093.820,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, single plane body section (eg, tomography), other than with urography ","code_information":[{"code":"324","type":"RC"},{"code":"76100","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":36.680,"maximum":44.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":41.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44.610,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of proximal fibula or shaft fracture; with manipulation ","code_information":[{"code":"27781","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; aortorenal ","code_information":[{"code":"35560","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, femoral condyles or tibial plateau(s), knee; ","code_information":[{"code":"27442","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"207","type":"RC"},{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12565.900,"maximum":15285.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14254.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15285.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14745.300,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, con ","code_information":[{"code":"49418","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT ","code_information":[{"code":"142","type":"RC"},{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15316.730,"maximum":15316.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15316.730,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy ","code_information":[{"code":"21502","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation ","code_information":[{"code":"27842","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"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":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose ","code_information":[{"code":"343","type":"RC"},{"code":"Q2057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1656833.000,"maximum":1656833.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1656833.000,"methodology":"fee schedule"}]}]},{"description":"REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED ","code_information":[{"code":"369","type":"RC"},{"code":"49561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":36505.570,"maximum":36505.570,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":36505.570,"methodology":"fee schedule"}]}]},{"description":"IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) ","code_information":[{"code":"306","type":"RC"},{"code":"81262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":64.090,"maximum":80.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":64.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":75.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":64.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":75.410,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":68.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":80.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":68.550,"methodology":"fee schedule"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12746.820,"maximum":12746.820,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12746.820,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, maxillofacial area; without contrast material ","code_information":[{"code":"329","type":"RC"},{"code":"70486","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":53.840,"maximum":65.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":53.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":65.480,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater ","code_information":[{"code":"21554","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11773.740,"maximum":11773.740,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11773.740,"methodology":"fee schedule"}]}]},{"description":"Inj pegfilgrastim-bmez 0. ","code_information":[{"code":"09345","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":115.720,"maximum":115.720,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":115.720,"methodology":"fee schedule"}]}]},{"description":"Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":139.640,"maximum":6438.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":170.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":193.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":170.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":207.550,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":171.790,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":139.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6438.740,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"210","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15596.900,"maximum":15596.900,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15596.900,"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":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Vulvectomy, radical, partial; ","code_information":[{"code":"56630","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture and/or ligation of thoracic duct; abdominal approach ","code_information":[{"code":"367","type":"RC"},{"code":"38382","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"134","type":"RC"},{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9027.030,"maximum":9027.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9027.030,"methodology":"fee schedule"}]}]},{"description":"Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, renin), radiological supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"75893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179.290,"maximum":6378.730,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":179.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6378.730,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28935.530,"maximum":28935.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28935.530,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive ","code_information":[{"code":"29898","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6315.830,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Incision, extensor tendon sheath, wrist (eg, de Quervains disease) ","code_information":[{"code":"25000","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VEIN LIGATION AND STRIPPING ","code_information":[{"code":"154","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23361.560,"maximum":23361.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23361.560,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy, radical, complete; ","code_information":[{"code":"369","type":"RC"},{"code":"56633","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS ","code_information":[{"code":"065","type":"MS-DRG"},{"code":"130","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8768.250,"maximum":8768.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8768.250,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of nasal bone fracture with manipulation; with stabilization ","code_information":[{"code":"21320","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography ","code_information":[{"code":"329","type":"RC"},{"code":"78635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":617.630,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":617.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage disease, type 1a, von Gierke disease) gene analysis, common variants (eg, R83C, Q347X) ","code_information":[{"code":"312","type":"RC"},{"code":"81250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":58.490,"maximum":69.020,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":58.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":69.020,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":25114.520,"maximum":25114.520,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":25114.520,"methodology":"fee schedule"}]}]},{"description":"Enterectomy, resection of small intestine; with enterostomy ","code_information":[{"code":"362","type":"RC"},{"code":"44125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, abdomen, musculoskeletal system ","code_information":[{"code":"22999","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8768.960,"maximum":8768.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8768.960,"methodology":"fee schedule"}]}]},{"description":"Arsenic ","code_information":[{"code":"314","type":"RC"},{"code":"82175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.970,"maximum":22.380,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.970,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.380,"methodology":"fee schedule"}]}]},{"description":"Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, ","code_information":[{"code":"32998","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family ","code_information":[{"code":"36215","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each ","code_information":[{"code":"26725","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Initial treatment, first degree burn, when no more than local treatment is required ","code_information":[{"code":"16000","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) ","code_information":[{"code":"81225","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":272.420,"maximum":343.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":272.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":320.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":272.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":320.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":343.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.360,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List ","code_information":[{"code":"36227","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventri ","code_information":[{"code":"61864","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Clotting; factor VIII, VW factor, ristocetin cofactor ","code_information":[{"code":"311","type":"RC"},{"code":"85245","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.940,"maximum":27.070,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.070,"methodology":"fee schedule"}]}]},{"description":"Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure) ","code_information":[{"code":"0437T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT ","code_information":[{"code":"120","type":"RC"},{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15316.730,"maximum":15316.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15316.730,"methodology":"fee schedule"}]}]},{"description":"Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) ","code_information":[{"code":"21073","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Reduction of craniomegalic skull (eg, treated hydrocephalus); requiring craniotomy and reconstruction with or without bone graft (includes obtaining grafts) ","code_information":[{"code":"62117","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, maxillofacial area; without contrast material ","code_information":[{"code":"351","type":"RC"},{"code":"70486","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":245.180,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST PROCEDURES WITH MCC ","code_information":[{"code":"163","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21528.360,"maximum":23303.900,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":23303.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":21528.360,"methodology":"fee schedule"}]}]},{"description":"Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantificatio ","code_information":[{"code":"618","type":"RC"},{"code":"78481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Proctosigmoidoscopy, rigid; with biopsy, single or multiple ","code_information":[{"code":"362","type":"RC"},{"code":"45305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"219","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27412.840,"maximum":27412.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27412.840,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral ","code_information":[{"code":"32666","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older ","code_information":[{"code":"33954","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"63012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Amniocentesis; diagnostic ","code_information":[{"code":"59000","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14376.460,"maximum":14376.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14376.460,"methodology":"fee schedule"}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23098.510,"maximum":23098.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23098.510,"methodology":"fee schedule"}]}]},{"description":"Aortoplasty (gusset) for supravalvular stenosis ","code_information":[{"code":"33417","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Glossectomy; partial, with unilateral radical neck dissection ","code_information":[{"code":"41135","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture of sciatic nerve ","code_information":[{"code":"64858","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) ","code_information":[{"code":"31641","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Angiography, internal mammary, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75756","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":160.250,"maximum":194.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":160.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":181.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":160.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":194.890,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction ","code_information":[{"code":"24535","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER HEART ASSIST SYSTEM IMPLANT ","code_information":[{"code":"201","type":"RC"},{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":72547.200,"maximum":72547.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":72547.200,"methodology":"fee schedule"}]}]},{"description":"Closure of vesicovaginal fistula; transvesical and vaginal approach ","code_information":[{"code":"360","type":"RC"},{"code":"57330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12724.600,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC ","code_information":[{"code":"075","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15235.480,"maximum":15235.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15235.480,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when perfor ","code_information":[{"code":"52284","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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 ","code_information":[{"code":"0109U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":142.630,"maximum":168.300,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":168.300,"methodology":"fee schedule"}]}]},{"description":"Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm ","code_information":[{"code":"490","type":"RC"},{"code":"69728","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"485","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24571.300,"maximum":24571.300,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24571.300,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"183","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12472.360,"maximum":12472.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12472.360,"methodology":"fee schedule"}]}]},{"description":"SKIN ULCERS WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15362.360,"maximum":15362.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15362.360,"methodology":"fee schedule"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic ","code_information":[{"code":"22206","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation ","code_information":[{"code":"27536","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and developme ","code_information":[{"code":"90964","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":399.780,"maximum":399.780,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":399.780,"methodology":"fee schedule"}]}]},{"description":"Injection, golimumab, 1 mg, for intravenous use ","code_information":[{"code":"891","type":"RC"},{"code":"J1602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":25.000,"maximum":25.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.000,"methodology":"fee schedule"}]}]},{"description":"Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery ","code_information":[{"code":"369","type":"RC"},{"code":"54056","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Perirectal injection of sclerosing solution for prolapse ","code_information":[{"code":"45520","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with transendoscopic endobronchial ultrasound (ebus) during bronchoscopic dia ","code_information":[{"code":"499","type":"RC"},{"code":"C7512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Resection prosthesis, mandibular implant/abutment supported removable prosthesis for edentulous arch ","code_information":[{"code":"499","type":"RC"},{"code":"D5943","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report ","code_information":[{"code":"304","type":"RC"},{"code":"86078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":139.460,"maximum":164.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":139.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":164.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":139.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":164.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Peridontal medicament carrier with peripheral seal - laboratory processed - maxillary ","code_information":[{"code":"361","type":"RC"},{"code":"D5995","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC ","code_information":[{"code":"127","type":"RC"},{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20528.580,"maximum":20528.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20528.580,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9261.560,"maximum":9261.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9261.560,"methodology":"fee schedule"}]}]},{"description":"Nerve conduction studies; 11-12 studies ","code_information":[{"code":"818459","type":"CDM"},{"code":"95912","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":1334.310,"maximum":1389.910,"gross_charge":11261.00,"discounted_cash":11261.00,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1362.110,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":1389.910,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1334.310,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":1362.110,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":1389.910,"methodology":"fee schedule"}]}]},{"description":"Exploration of epididymis, with or without biopsy ","code_information":[{"code":"54865","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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; initial and subsequ ","code_information":[{"code":"20696","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC ","code_information":[{"code":"202","type":"RC"},{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11157.820,"maximum":11157.820,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11157.820,"methodology":"fee schedule"}]}]},{"description":" Blood and Blood Components Other Blood Components  ","code_information":[{"code":"386","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Penile revascularization, artery, with or without vein graft ","code_information":[{"code":"361","type":"RC"},{"code":"37788","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance ","code_information":[{"code":"0888T","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9097.420,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC ","code_information":[{"code":"169","type":"RC"},{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12254.940,"maximum":12254.940,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12254.940,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9300.060,"maximum":9300.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9300.060,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9300.060,"maximum":9300.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9300.060,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9123.270,"maximum":15285.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9123.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14254.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15285.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14745.300,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32415.080,"maximum":32415.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":32415.080,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendonºs», muscleºs», nerveºs», other soft-tissue structureºs», or soft-tiss ","code_information":[{"code":"611","type":"RC"},{"code":"76882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC One Day Stay","code_information":[{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33381.030,"maximum":33381.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33381.030,"methodology":"fee schedule"}]}]},{"description":"Bone and/or joint imaging; multiple areas ","code_information":[{"code":"610","type":"RC"},{"code":"78305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements ","code_information":[{"code":"0050U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2727.020,"maximum":3441.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2727.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3208.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2727.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3208.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2916.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3441.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2916.600,"methodology":"fee schedule"}]}]},{"description":"Level 3 Type A ED Visits ","code_information":[{"code":"05023","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":245.840,"maximum":245.840,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":245.840,"methodology":"fee schedule"}]}]},{"description":"Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis ","code_information":[{"code":"27217","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"17261","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"094","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":26655.050,"maximum":26655.050,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26655.050,"methodology":"fee schedule"}]}]},{"description":"Inj lenacapavir (hiv tx) ","code_information":[{"code":"09155","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":21.630,"maximum":21.630,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":21.630,"methodology":"fee schedule"}]}]},{"description":"PREMATURITY WITHOUT MAJOR PROBLEMS ","code_information":[{"code":"201","type":"RC"},{"code":"792","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19025.830,"maximum":19025.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19025.830,"methodology":"fee schedule"}]}]},{"description":"TRANSPERINEAL PERIURETHRAL BALLOON CONTINENCE DEVICE; BILATERAL PLACEMENT, INCLUDING CYSTOSCOPY AND FLUOROSCOPY ","code_information":[{"code":"0548T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer ","code_information":[{"code":"0433U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":710.600,"maximum":896.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"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":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Technetium tc-99m succimer, diagnostic, per study dose, up to 10 millicuries ","code_information":[{"code":"891","type":"RC"},{"code":"A9551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1418.850,"maximum":1418.850,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1418.850,"methodology":"fee schedule"}]}]},{"description":"SKIN ULCERS WITH CC ","code_information":[{"code":"117","type":"RC"},{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10022.920,"maximum":10022.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10022.920,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"74261","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":422.760,"maximum":514.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":422.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":479.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":422.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":514.150,"methodology":"fee schedule"}]}]},{"description":"Shunt; superior vena cava to pulmonary artery for flow to both lungs (bidirectional Glenn procedure) ","code_information":[{"code":"33767","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Osteotomy, femur, shaft or supracondylar; without fixation ","code_information":[{"code":"27448","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, elbow, surgical; debridement, extensive ","code_information":[{"code":"29838","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Myelography, 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"72270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":932.270,"maximum":932.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":932.270,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20047.390,"maximum":20047.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20047.390,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"027","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19551.220,"maximum":19551.220,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19551.220,"methodology":"fee schedule"}]}]},{"description":"Biopsy, prostate, in-bore CT- or MRI-guided targeted lesion(s) only, first targeted lesion ","code_information":[{"code":"369","type":"RC"},{"code":"55714","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"PMS2 (postmeiotic segregation increased 2 ºS. cerevisiae») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"319","type":"RC"},{"code":"81319","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":203.500,"maximum":240.130,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":203.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":240.130,"methodology":"fee schedule"}]}]},{"description":"Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion ","code_information":[{"code":"17000","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Fructose, semen ","code_information":[{"code":"306","type":"RC"},{"code":"82757","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.210,"maximum":20.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.070,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.340,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.340,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; with contrast material ","code_information":[{"code":"610","type":"RC"},{"code":"72129","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; sulfhemoglobin, quantitative ","code_information":[{"code":"303","type":"RC"},{"code":"83060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.230,"maximum":10.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.800,"methodology":"fee schedule"}]}]},{"description":"Surgical repair of root resorption - molar ","code_information":[{"code":"369","type":"RC"},{"code":"D3473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) ","code_information":[{"code":"367","type":"RC"},{"code":"64451","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (ie, CT or fluoroscopy), bilateral; one interspace, lum ","code_information":[{"code":"62330","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) ","code_information":[{"code":"82952","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.360,"maximum":6.820,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3.530,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":3.960,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3.530,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":3.530,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":4.120,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":4.040,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":4.120,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":6.820,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":5.880,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":4.120,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":4.120,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":3.800,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":3.960,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":3.960,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":3.960,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":3.360,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":5.880,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":4.120,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":3.920,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":4.000,"methodology":"fee schedule"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18237.390,"maximum":18237.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18237.390,"methodology":"fee schedule"}]}]},{"description":"Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separa ","code_information":[{"code":"361","type":"RC"},{"code":"36479","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of ","code_information":[{"code":"33270","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4178.000,"maximum":72100.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":31633.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":35884.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":31633.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38478.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":37120.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13614.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":72100.000,"methodology":"case rate"}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11232.670,"maximum":11232.670,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11232.670,"methodology":"fee schedule"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process ","code_information":[{"code":"24147","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"206","type":"RC"},{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15786.520,"maximum":15786.520,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15786.520,"methodology":"fee schedule"}]}]},{"description":"Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) ","code_information":[{"code":"64629","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis; triple ","code_information":[{"code":"28715","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination; orbits, complete, minimum of 4 views ","code_information":[{"code":"329","type":"RC"},{"code":"70200","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":17.730,"maximum":21.570,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.570,"methodology":"fee schedule"}]}]},{"description":"Osteoplasty, femur; shortening (excluding 64876) ","code_information":[{"code":"27465","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gastrin ","code_information":[{"code":"311","type":"RC"},{"code":"82941","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.630,"maximum":20.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.800,"methodology":"fee schedule"}]}]},{"description":"Antibody; influenza virus ","code_information":[{"code":"305","type":"RC"},{"code":"86710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.670,"maximum":15.990,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.910,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.550,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, bone marrow blood supply ","code_information":[{"code":"322","type":"RC"},{"code":"77084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":595.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":439.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":499.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":439.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":535.030,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":595.800,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":365.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14362.200,"maximum":14362.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14362.200,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WIT ","code_information":[{"code":"202","type":"RC"},{"code":"428","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":41644.000,"maximum":41644.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":41644.000,"methodology":"fee schedule"}]}]},{"description":"Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral or bilateral for pelvic bone fracture patterns which do not disrupt the pelvic ring includes internal fixat ","code_information":[{"code":"360","type":"RC"},{"code":"G0412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) ","code_information":[{"code":"307","type":"RC"},{"code":"81341","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46.370,"maximum":58.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":46.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":54.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":46.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":54.550,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":49.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":58.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.590,"methodology":"fee schedule"}]}]},{"description":"Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); without pancreatojejunostomy ","code_information":[{"code":"480","type":"RC"},{"code":"48154","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Suture of posterior tibial nerve ","code_information":[{"code":"499","type":"RC"},{"code":"64840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC ","code_information":[{"code":"167","type":"RC"},{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6810.690,"maximum":6810.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6810.690,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, radiostereometric analysis (RSA); spine, (includes cervical, thoracic and lumbosacral, when performed) ","code_information":[{"code":"0348T","type":"CPT"},{"code":"409","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":245.180,"maximum":245.180,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Neurology (autism), 32 amines by LC-MS/MS, using plasma, algorithm reported as metabolic signature associated with autism spectrum disorder ","code_information":[{"code":"0063U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":701.250,"maximum":885.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":701.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":825.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":701.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":825.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":750.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":885.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":750.000,"methodology":"fee schedule"}]}]},{"description":"Chromotubation of oviduct, including materials ","code_information":[{"code":"58350","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES ","code_information":[{"code":"018","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":309406.200,"maximum":309406.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":309406.200,"methodology":"fee schedule"}]}]},{"description":"Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure) ","code_information":[{"code":"320","type":"RC"},{"code":"76125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.970,"maximum":26.970,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":26.970,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":14.970,"methodology":"fee schedule"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"144","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22568.120,"maximum":22568.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22568.120,"methodology":"fee schedule"}]}]},{"description":"Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery) ","code_information":[{"code":"67825","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":6444.990,"maximum":6444.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6444.990,"methodology":"fee schedule"}]}]},{"description":"Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint ","code_information":[{"code":"26685","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"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":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, foot; 2 views ","code_information":[{"code":"320","type":"RC"},{"code":"73620","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":10.400,"maximum":12.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.650,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC ","code_information":[{"code":"158","type":"MS-DRG"},{"code":"172","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8051.810,"maximum":8051.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8051.810,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, adductor of hip, percutaneous (separate procedure) ","code_information":[{"code":"27000","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion ","code_information":[{"code":"369","type":"RC"},{"code":"63620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) ","code_information":[{"code":"61782","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hydroxyproline; total ","code_information":[{"code":"311","type":"RC"},{"code":"83505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.300,"maximum":28.670,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":24.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":28.670,"methodology":"fee schedule"}]}]},{"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":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Venography, renal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75833","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":96.000,"maximum":116.750,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":96.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":108.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":96.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":116.750,"methodology":"fee schedule"}]}]},{"description":"Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element ","code_information":[{"code":"0238U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":546.880,"maximum":690.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":546.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":643.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":546.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":643.390,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":584.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":690.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":584.900,"methodology":"fee schedule"}]}]},{"description":"Collection of venous blood by venipuncture ","code_information":[{"code":"362","type":"RC"},{"code":"36415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis ","code_information":[{"code":"303","type":"RC"},{"code":"81288","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179.820,"maximum":226.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":179.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":211.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":179.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":211.550,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":192.320,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":226.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":192.320,"methodology":"fee schedule"}]}]},{"description":"Intersex surgery; male to female ","code_information":[{"code":"369","type":"RC"},{"code":"55970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed ","code_information":[{"code":"77402","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":275.370,"maximum":286.840,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":281.100,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":286.840,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":275.370,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":281.100,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":286.840,"methodology":"fee schedule"}]}]},{"description":"Excision of bulbourethral gland (Cowper's gland) ","code_information":[{"code":"362","type":"RC"},{"code":"53250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12629.910,"maximum":12629.910,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12629.910,"methodology":"fee schedule"}]}]},{"description":"Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus ","code_information":[{"code":"61598","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in additi ","code_information":[{"code":"19282","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (bladder),DNA,nextgeneration sequencing (NGS) of 60 genes and whole genome aneuploidy,urine,altorighms reported as minimal residual disease (MRD) status positive or negative and quantitative ","code_information":[{"code":"0467U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1420.320,"maximum":1792.490,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1420.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1670.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1420.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1670.970,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1792.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1519.060,"methodology":"fee schedule"}]}]},{"description":"Biopsy of spinal cord, percutaneous needle ","code_information":[{"code":"369","type":"RC"},{"code":"62269","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK ","code_information":[{"code":"3032","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":44052.620,"maximum":66078.930,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":44052.620,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":44933.670,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":66078.930,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":44052.620,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":44052.620,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":44052.620,"methodology":"fee schedule"}]}]},{"description":"Oncology (colorectal cancer), eval for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, IPK3CA, SMAD4, and TP53, and methylation markers, multiplex quantitative polymerase chain reaction (qPCR), circulatin ","code_information":[{"code":"0368U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":389.690,"maximum":491.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":389.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":458.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":389.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":458.460,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":491.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"}]}]},{"description":"TESTES PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"712","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9405.560,"maximum":9405.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9405.560,"methodology":"fee schedule"}]}]},{"description":"Wilate injection ","code_information":[{"code":"01352","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.280,"maximum":1.280,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":1.280,"methodology":"fee schedule"}]}]},{"description":"Targeted genomic sequence analysis panel, solid organ neoplasm, circulating cell-free DNA (cfDNA) analysis from plasma of 521 genes, interrogation for sequence variants, ","code_information":[{"code":"0585U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2729.830,"maximum":3445.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2729.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3211.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2729.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3211.560,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3445.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2919.600,"methodology":"fee schedule"}]}]},{"description":"C-reactive protein; ","code_information":[{"code":"300","type":"RC"},{"code":"86140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.840,"maximum":6.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.180,"methodology":"fee schedule"}]}]},{"description":"Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient a ","code_information":[{"code":"G0557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":74.910,"maximum":78.030,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":76.470,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":78.030,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":74.910,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":76.470,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":78.030,"methodology":"fee schedule"}]}]},{"description":"Colectomy, total, abdominal, with proctectomy; with ileostomy ","code_information":[{"code":"44155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment ","code_information":[{"code":"32701","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6342.330,"maximum":6342.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6342.330,"methodology":"fee schedule"}]}]},{"description":"RECTAL RESECTION WITH CC ","code_information":[{"code":"152","type":"RC"},{"code":"333","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18263.060,"maximum":18263.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18263.060,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC ","code_information":[{"code":"190","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9462.590,"maximum":9462.590,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9462.590,"methodology":"fee schedule"}]}]},{"description":"Donor pneumonectomy(s) (including cold preservation), from cadaver donor ","code_information":[{"code":"32850","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) ","code_information":[{"code":"300","type":"RC"},{"code":"83701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.660,"maximum":39.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":31.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":31.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37.250,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":33.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":39.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33.860,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"612","type":"RC"},{"code":"75885","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"Galectin-3 ","code_information":[{"code":"307","type":"RC"},{"code":"82777","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.370,"maximum":52.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":48.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":48.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":44.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":52.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":44.250,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES ","code_information":[{"code":"202","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9200.260,"maximum":9200.260,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9200.260,"methodology":"fee schedule"}]}]},{"description":"Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"61050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis ","code_information":[{"code":"0094U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7089.360,"maximum":8947.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7089.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8340.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7089.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8340.420,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7582.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8947.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7582.200,"methodology":"fee schedule"}]}]},{"description":"Oncology (hematolymphoid neoplasm), genomic seq anal using multiplex (PCR) & next gen seq w altorithm, quantification of dominatnt clonal sequ, reported as presence or absence of minimal residual dise ","code_information":[{"code":"0364U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2007.250,"maximum":2368.550,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2007.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2368.550,"methodology":"fee schedule"}]}]},{"description":"Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Wharton's) ducts ","code_information":[{"code":"42510","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter re ","code_information":[{"code":"47539","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level ","code_information":[{"code":"499","type":"RC"},{"code":"64490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; ","code_information":[{"code":"362","type":"RC"},{"code":"63050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"324","type":"RC"},{"code":"74400","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":30.730,"maximum":37.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":30.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":34.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":30.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37.380,"methodology":"fee schedule"}]}]},{"description":"Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion ","code_information":[{"code":"499","type":"RC"},{"code":"69745","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views ","code_information":[{"code":"351","type":"RC"},{"code":"73522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5? gene duplication/multiplication) (List separately in addition to ","code_information":[{"code":"0075U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":421.600,"maximum":532.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":421.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":496.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":421.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":496.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":450.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":532.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":450.910,"methodology":"fee schedule"}]}]},{"description":"Insertion of implantable defibrillator pulse generator only; with existing single lead ","code_information":[{"code":"33240","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3162.000,"maximum":72100.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":31633.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":35884.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":31633.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38478.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":37120.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":4135.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3435.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":4096.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":72100.000,"methodology":"case rate"}]}]},{"description":"Tracheostoma revision; simple, without flap rotation ","code_information":[{"code":"31613","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophageal recording of atrial electrogram with or without ventricular electrogram(s); ","code_information":[{"code":"93615","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":2928.890,"maximum":3050.930,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":2989.910,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":3050.930,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2928.890,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":2989.910,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":3050.930,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with internal urethrotomy; male ","code_information":[{"code":"52275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":5015.140,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4914.840,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":5015.140,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4814.530,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":4914.840,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":5015.140,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9837.570,"maximum":9837.570,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9837.570,"methodology":"fee schedule"}]}]},{"description":"Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75746","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":117.730,"maximum":143.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":117.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":133.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":117.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":143.180,"methodology":"fee schedule"}]}]},{"description":"Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies ","code_information":[{"code":"0810T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy ","code_information":[{"code":"44604","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"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":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9104.020,"maximum":9104.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9104.020,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural space, without biopsy ","code_information":[{"code":"32601","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23095.650,"maximum":23095.650,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23095.650,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy ","code_information":[{"code":"499","type":"RC"},{"code":"56634","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Use of ophthalmic endoscope (List separately in addition to code for primary procedure) ","code_information":[{"code":"66990","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each ","code_information":[{"code":"26756","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"213","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7765.230,"maximum":7765.230,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7765.230,"methodology":"fee schedule"}]}]},{"description":"Intraoperative radiation treatment delivery, electrons, single treatment session ","code_information":[{"code":"350","type":"RC"},{"code":"77425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9020.500,"maximum":9020.500,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9020.500,"methodology":"fee schedule"}]}]},{"description":"DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) ","code_information":[{"code":"303","type":"RC"},{"code":"81239","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS ","code_information":[{"code":"33988","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study ","code_information":[{"code":"341","type":"RC"},{"code":"74221","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14362.200,"maximum":14362.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14362.200,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed ","code_information":[{"code":"43284","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, unilateral or bilateral; remote surveillance center technical su ","code_information":[{"code":"0605T","type":"CPT"},{"code":"324","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":83.590,"maximum":83.590,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":83.590,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, wrist, with or without interposition, with or without external or internal fixation ","code_information":[{"code":"25332","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22240.920,"maximum":22240.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22240.920,"methodology":"fee schedule"}]}]},{"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":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3200.000,"maximum":3776.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3200.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3776.000,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC ","code_information":[{"code":"098","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":17925.870,"maximum":17925.870,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17925.870,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0D1A4JA","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3296.000,"maximum":3296.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3296.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Radiologic examination, knee; 1 or 2 views ","code_information":[{"code":"320","type":"RC"},{"code":"73560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.780,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":48.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":54.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":48.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":58.600,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":43.640,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":37.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Urography (pyelography), intravenous, with or without KUB, with or without tomography ","code_information":[{"code":"616","type":"RC"},{"code":"74400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction ","code_information":[{"code":"306","type":"RC"},{"code":"81261","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":185.120,"maximum":233.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":185.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":217.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":185.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":217.790,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":197.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":233.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":197.990,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation ","code_information":[{"code":"341","type":"RC"},{"code":"76881","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"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":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure) ","code_information":[{"code":"20985","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy, with internal urethrotomy; male ","code_information":[{"code":"480","type":"RC"},{"code":"52275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Gastroenterology (irritable bowel disease (IBD), immunoassay for quantitative determination of adalimumab (ADL) levels in venous serum in patients undergoing adalimumab therapy, results reported as a ","code_information":[{"code":"0514U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":36.060,"maximum":45.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.430,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":38.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":45.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38.570,"methodology":"fee schedule"}]}]},{"description":"Injection, oxacillin sodium, up to 250 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J2700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.230,"maximum":1.230,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.230,"methodology":"fee schedule"}]}]},{"description":"Special medical radiation physics consultation ","code_information":[{"code":"329","type":"RC"},{"code":"77370","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":156.670,"maximum":156.670,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":156.670,"methodology":"fee schedule"}]}]},{"description":"Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. ","code_information":[{"code":"343","type":"RC"},{"code":"J7213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.450,"maximum":4.450,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.450,"methodology":"fee schedule"}]}]},{"description":"Replacement, aortic valve, open, with cardiopulmonary bypass; with stentless tissue valve ","code_information":[{"code":"33410","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection, eribulin mesylate, 0.1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J9179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":156.110,"maximum":156.110,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":156.110,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Tympanic neurectomy ","code_information":[{"code":"480","type":"RC"},{"code":"69676","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12165.830,"maximum":12165.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12165.830,"methodology":"fee schedule"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach ","code_information":[{"code":"33362","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Ethmoidectomy; intranasal, anterior ","code_information":[{"code":"31200","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Insertion of pacemaker pulse generator only; with existing single lead ","code_information":[{"code":"33212","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":40306.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12517.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14199.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12517.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15225.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14688.000,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":39140.000,"methodology":"case rate"}]}]},{"description":"RECTAL RESECTION WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27377.190,"maximum":27377.190,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27377.190,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0347U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1249.240,"maximum":1576.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1249.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1469.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1249.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1469.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1336.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1576.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1336.090,"methodology":"fee schedule"}]}]},{"description":"Repair of omphalocele (Gross type operation); first stage ","code_information":[{"code":"49610","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"024","type":"MS-DRG"},{"code":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":29453.090,"maximum":29453.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":29453.090,"methodology":"fee schedule"}]}]},{"description":"Acesso trifaca, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis ","code_information":[{"code":"0155U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next generation sequencing, formalin-fixed paraffin embedded or fresh tissue, predictive, rep ","code_information":[{"code":"0008U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":559.050,"maximum":705.530,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":559.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":657.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":559.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":657.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":597.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":705.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":597.910,"methodology":"fee schedule"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23189.040,"maximum":23189.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23189.040,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with thoracic sympathectomy ","code_information":[{"code":"32664","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11066.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure) ","code_information":[{"code":"0133U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":669.580,"maximum":1035.430,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":697.190,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":724.800,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":711.000,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":704.100,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":724.800,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":704.100,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":1035.430,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":724.800,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":724.800,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":669.580,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":828.350,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":697.190,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":697.190,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":697.190,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":1035.430,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":724.800,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":704.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":704.100,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15902.010,"maximum":15902.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15902.010,"methodology":"fee schedule"}]}]},{"description":"Maxillary guidance prosthesis without guide flange ","code_information":[{"code":"361","type":"RC"},{"code":"D5930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) ","code_information":[{"code":"21146","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft ","code_information":[{"code":"30520","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Hepatitis B surface antibody (HBsAb) ","code_information":[{"code":"302","type":"RC"},{"code":"86706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.040,"maximum":12.670,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.810,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.740,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"76080","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":49.160,"maximum":59.780,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":49.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":55.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":49.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59.780,"methodology":"fee schedule"}]}]},{"description":"Tenodesis at wrist; extensors of fingers ","code_information":[{"code":"25301","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"213","type":"RC"},{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24594.830,"maximum":24594.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24594.830,"methodology":"fee schedule"}]}]},{"description":"Introduction of needle or intracatheter, aortic, translumbar ","code_information":[{"code":"36160","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Carbamazepine; -10,11-epoxide ","code_information":[{"code":"314","type":"RC"},{"code":"80161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.640,"maximum":22.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.000,"methodology":"fee schedule"}]}]},{"description":"Treatment of septic abortion, completed surgically ","code_information":[{"code":"59830","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, skull; less than 4 views ","code_information":[{"code":"324","type":"RC"},{"code":"70250","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":11.770,"maximum":14.320,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.320,"methodology":"fee schedule"}]}]},{"description":"Injection, enoxaparin sodium, 10 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J1650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.140,"maximum":1.140,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.140,"methodology":"fee schedule"}]}]},{"description":"PULMONARY; M > 29.15 & M < 39.05 ","code_information":[{"code":"148","type":"RC"},{"code":"D1503","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":21990.080,"maximum":25163.910,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":24030.400,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22670.190,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25163.910,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":23803.700,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":21990.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22896.890,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":22896.890,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":22896.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22670.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":25163.910,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":25163.910,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"120","type":"RC"},{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9320.730,"maximum":9320.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9320.730,"methodology":"fee schedule"}]}]},{"description":"Advograft one, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) ","code_information":[{"code":"23532","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each ","code_information":[{"code":"28308","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of humeral condylar fracture, medial or lateral; without manipulation ","code_information":[{"code":"24576","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC ","code_information":[{"code":"074","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8914.390,"maximum":8914.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8914.390,"methodology":"fee schedule"}]}]},{"description":"Injection, leuprolide acetate (for depot suspension), per 3.75 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3792.320,"maximum":3792.320,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3792.320,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10010","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with other than vein; iliorenal ","code_information":[{"code":"35634","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment ","code_information":[{"code":"32701","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"AMPUTATION, LOWER EXTREMITY; M > 47.65 ","code_information":[{"code":"148","type":"RC"},{"code":"B1001","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19212.010,"maximum":21984.880,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20994.570,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19806.190,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21984.880,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20796.500,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":19212.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20004.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20004.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20004.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19806.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":21984.880,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":21984.880,"methodology":"fee schedule"}]}]},{"description":"Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, secondary repair) ","code_information":[{"code":"51841","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when perf ","code_information":[{"code":"616","type":"RC"},{"code":"77049","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.920,"maximum":635.920,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":635.920,"methodology":"fee schedule"}]}]},{"description":"Injection, nitroglycerin, 5 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J2305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.270,"maximum":3.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.270,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH CC ","code_information":[{"code":"152","type":"RC"},{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneu ","code_information":[{"code":"37285","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cranioplasty for skull defect; up to 5 cm diameter ","code_information":[{"code":"62140","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11408.750,"maximum":11408.750,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11408.750,"methodology":"fee schedule"}]}]},{"description":"Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component ","code_information":[{"code":"24370","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventri ","code_information":[{"code":"367","type":"RC"},{"code":"61863","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas ","code_information":[{"code":"352","type":"RC"},{"code":"78801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Frozen blood, each unit; thawing ","code_information":[{"code":"86931","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":303.760,"maximum":448.880,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":303.760,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":448.880,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":430.920,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":448.880,"methodology":"fee schedule"}]}]},{"description":"Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing forma ","code_information":[{"code":"305","type":"RC"},{"code":"81540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3506.250,"maximum":4425.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3506.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4125.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3506.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4125.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3750.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4425.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3750.000,"methodology":"fee schedule"}]}]},{"description":"Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia ","code_information":[{"code":"369","type":"RC"},{"code":"39503","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Incision, anal septum (infant) ","code_information":[{"code":"46070","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, diathermy ","code_information":[{"code":"367","type":"RC"},{"code":"67227","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Severing adhesions of anterior segment, laser technique (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"65860","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment ","code_information":[{"code":"24359","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length ","code_information":[{"code":"64885","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic angiography (CTA), head and neck, with contrast material(s), including noncontrast images, when performed, and image postprocessing ","code_information":[{"code":"329","type":"RC"},{"code":"70471","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":366.360,"maximum":445.560,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":366.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":415.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":366.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":445.560,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess ","code_information":[{"code":"45020","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"152","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16435.240,"maximum":16435.240,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16435.240,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC ","code_information":[{"code":"152","type":"RC"},{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6810.690,"maximum":6810.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6810.690,"methodology":"fee schedule"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC ","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":34742.400,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":31627.160,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":12379.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":31627.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":31627.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":31627.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":22590.830,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":28561.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32400.270,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":12624.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":28561.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34742.400,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":15320.980,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":12501.920,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":10418.260,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":10418.260,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":12501.920,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12501.920,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":16225.580,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":12747.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17205.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":12747.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":11889.080,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":12904.320,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12379.350,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":12379.350,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":12379.350,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":12256.780,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":12256.780,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":12256.780,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":16556.710,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":17343.530,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":14294.370,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":17178.800,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":13158.090,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":12747.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10744.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":15894.440,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":12747.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":16225.580,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":18385.170,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12869.620,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":12256.780,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":16556.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10391.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11999.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":12256.780,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":12256.780,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":12501.920,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"69310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"409","type":"RC"},{"code":"70498","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":108.620,"maximum":132.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":108.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":123.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":108.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":132.100,"methodology":"fee schedule"}]}]},{"description":"Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple ","code_information":[{"code":"46607","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"0652T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7284.450,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"173","type":"RC"},{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12361.860,"maximum":12361.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12361.860,"methodology":"fee schedule"}]}]},{"description":"Rho(D) immune globulin (RhIgIV), human, for intravenous use ","code_information":[{"code":"343","type":"RC"},{"code":"90386","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1429.210,"maximum":1429.210,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1429.210,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"803","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14817.720,"maximum":14817.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14817.720,"methodology":"fee schedule"}]}]},{"description":" Laboratory Immunology   ","code_information":[{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_percentage":24.10,"standard_charge_algorithm":"Reimbursement will be 24.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":27.40,"standard_charge_algorithm":"Reimbursement will be 27.4% of billable gross charges.","median_amount":17.300,"10th_percentile":5.180,"90th_percentile":105.650,"count":"88","methodology":"percent of total billed charges","additional_payer_notes":" Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_percentage":24.10,"standard_charge_algorithm":"Reimbursement will be 24.1% of billable gross charges.","median_amount":33.190,"10th_percentile":13.340,"90th_percentile":672.510,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":29.40,"standard_charge_algorithm":"Reimbursement will be 29.4% of billable gross charges.","median_amount":19.460,"10th_percentile":4.840,"90th_percentile":145.890,"count":"118","methodology":"percent of total billed charges","additional_payer_notes":" 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_percentage":36.30,"standard_charge_algorithm":"In addition to other contracted rates, reimbursement will be 36.3% of billable gross charges in addition to other contracted rates.","median_amount":218.890,"10th_percentile":53.270,"90th_percentile":395.290,"count":"35","methodology":"percent of total billed charges","additional_payer_notes":" Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_percentage":27.20,"standard_charge_algorithm":"In addition to other contracted rates, reimbursement will be 27.2% of billable gross charges in addition to other contracted rates.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"OAP","standard_charge_percentage":36.30,"standard_charge_algorithm":"In addition to other contracted rates, reimbursement will be 36.3% of billable gross charges in addition to other contracted rates.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"PPO","standard_charge_percentage":36.30,"standard_charge_algorithm":"In addition to other contracted rates, reimbursement will be 36.3% of billable gross charges in addition to other contracted rates.","median_amount":218.890,"10th_percentile":53.270,"90th_percentile":395.290,"count":"35","methodology":"percent of total billed charges","additional_payer_notes":" Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","median_amount":5440.000,"10th_percentile":5440.000,"90th_percentile":5440.000,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","median_amount":48.190,"10th_percentile":4.400,"90th_percentile":326.360,"count":"49","methodology":"percent of total billed charges","additional_payer_notes":" Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"INSERTION OF CANNULA(S) ","code_information":[{"code":"36822","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Venography for congenital heart defect(s), including catheter placement, and radiological supervision and interpretation; venovenous collaterals originating at or above the heart (eg, from innominate ","code_information":[{"code":"360","type":"RC"},{"code":"93587","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or fulguration of carcinoma of urethra ","code_information":[{"code":"53220","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Muscle, myocutaneous, or fasciocutaneous flap; upper extremity ","code_information":[{"code":"15736","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination; tibia and fibula, 2 views ","code_information":[{"code":"350","type":"RC"},{"code":"73590","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH MCC ","code_information":[{"code":"135","type":"RC"},{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8118.110,"maximum":8118.110,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8118.110,"methodology":"fee schedule"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"174","type":"RC"},{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14425.640,"maximum":14425.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14425.640,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes ","code_information":[{"code":"369","type":"RC"},{"code":"51585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"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":"66982","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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, ribs, bilateral; including posteroanterior chest, minimum of 4 views ","code_information":[{"code":"323","type":"RC"},{"code":"71111","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":51.520,"maximum":62.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":51.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":58.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":51.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":62.650,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family ","code_information":[{"code":"362","type":"RC"},{"code":"36217","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"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":36.840,"maximum":44.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":41.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44.800,"methodology":"fee schedule"}]}]},{"description":"PERIPH FIELD STIMUL REVISE ","code_information":[{"code":"0284T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score ","code_information":[{"code":"0069U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":380.000,"maximum":448.400,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":380.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":448.400,"methodology":"fee schedule"}]}]},{"description":"Lipoprotein (a) ","code_information":[{"code":"312","type":"RC"},{"code":"83695","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.320,"maximum":16.900,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.320,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.900,"methodology":"fee schedule"}]}]},{"description":"Injection, orphenadrine citrate, up to 60 mg ","drug_information":{"unit":6.000000000000000e+001,"type":"ME"},"code_information":[{"code":"913414","type":"CDM"},{"code":"J2360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":10.570,"maximum":15.860,"gross_charge":370.50,"discounted_cash":370.50,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":11.400,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":15.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":11.960,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":10.570,"methodology":"fee schedule"}]}]},{"description":"Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus ","code_information":[{"code":"33411","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Trabeculotomy by laser, including optical coherence tomography (OCT) guidance ","code_information":[{"code":"0730T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7417.150,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Flortaucipir f 18 injection, diagnostic, 1 millicurie ","code_information":[{"code":"892","type":"RC"},{"code":"A9601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":797.650,"maximum":797.650,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":797.650,"methodology":"fee schedule"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC One Day Stay","code_information":[{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITH CC ","code_information":[{"code":"209","type":"RC"},{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16598.490,"maximum":16598.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16598.490,"methodology":"fee schedule"}]}]},{"description":"Repair lateral collateral ligament, elbow, with local tissue ","code_information":[{"code":"24343","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7967.210,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC One Day Stay","code_information":[{"code":"026","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm ","code_information":[{"code":"362","type":"RC"},{"code":"54308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence ","code_information":[{"code":"81189","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"167","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7774.500,"maximum":7774.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7774.500,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, percutaneous, single, each digit ","code_information":[{"code":"26060","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial ","code_information":[{"code":"21181","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) ","code_information":[{"code":"20680","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus ","code_information":[{"code":"64714","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ABORTION WITHOUT D&C ","code_information":[{"code":"133","type":"RC"},{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7563.490,"maximum":7563.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7563.490,"methodology":"fee schedule"}]}]},{"description":"Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventri ","code_information":[{"code":"61863","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"173","type":"RC"},{"code":"393","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12967.100,"maximum":12967.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12967.100,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"43200","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence ","code_information":[{"code":"81173","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":281.760,"maximum":355.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":281.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":331.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":281.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":331.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":355.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":301.350,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC ","code_information":[{"code":"164","type":"RC"},{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13403.380,"maximum":13403.380,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13403.380,"methodology":"fee schedule"}]}]},{"description":"Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram ","code_information":[{"code":"636","type":"RC"},{"code":"J7189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.630,"maximum":5.630,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.630,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27047.840,"maximum":27047.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27047.840,"methodology":"fee schedule"}]}]},{"description":"Injection of sinus tract; diagnostic (sinogram) ","code_information":[{"code":"20501","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Gastrectomy, partial, distal; with gastrojejunostomy ","code_information":[{"code":"43632","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with vein; axillary-femoral ","code_information":[{"code":"35521","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Probing of nasolacrimal duct, with or without irrigation; ","code_information":[{"code":"361","type":"RC"},{"code":"68810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE ","code_information":[{"code":"790","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":124813.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":9240.000,"methodology":"per diem"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":40711.240,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":9240.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":9240.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":9240.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":6600.000,"methodology":"per diem"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":102609.770,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $293412.00, reimbursement will be 32.2% of billable gross charges instead of the contracted rate."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":116399.290,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $293412.00, reimbursement will be 36.5% of billable gross charges instead of the contracted rate."},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":41517.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":102609.770,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $293412.00, reimbursement will be 32.2% of billable gross charges instead of the contracted rate."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":124813.500,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $293412.00, reimbursement will be 39.2% of billable gross charges instead of the contracted rate."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":50385.200,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":41114.320,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":34261.940,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":34261.940,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":41114.320,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":41114.320,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":57384.630,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":41920.490,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 17. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":41920.490,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 17. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":39098.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":40711.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":40711.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":40711.240,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":40308.160,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":40308.160,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":40308.160,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":58555.740,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":61338.450,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":50554.580,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":60755.860,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":46535.890,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":41920.490,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 17. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":56213.510,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":41920.490,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 17. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":57384.630,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":60462.240,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":42323.570,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":40308.160,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":58555.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3399.000,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":39461.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":40308.160,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":40308.160,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":41114.320,"methodology":"fee schedule"}]}]},{"description":"Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; each additional drug tested (List separately in addition to code for primary proce ","code_information":[{"code":"312","type":"RC"},{"code":"87904","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.070,"maximum":30.760,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":26.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.760,"methodology":"fee schedule"}]}]},{"description":"Level 4 Intraocular Proce ","code_information":[{"code":"5494","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":12604.900,"maximum":19492.110,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":13124.690,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":13384.580,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":13644.480,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":13254.630,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12994.740,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":13644.480,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":13644.480,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":12604.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13124.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":13124.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":13124.690,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":12994.740,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":12994.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":12994.740,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":19492.110,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13644.480,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":12994.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13254.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":12994.740,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":13254.630,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH CC ","code_information":[{"code":"122","type":"RC"},{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12629.910,"maximum":12629.910,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12629.910,"methodology":"fee schedule"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH CC One Day Stay","code_information":[{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HEART FAILURE AND SHOCK WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10717.970,"maximum":10717.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10717.970,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, head; with contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"70545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":317.290,"maximum":510.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":317.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":359.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":317.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":385.870,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":510.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Gases, blood, pH only ","code_information":[{"code":"306","type":"RC"},{"code":"82800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.290,"maximum":12.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.000,"methodology":"fee schedule"}]}]},{"description":"Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle ","code_information":[{"code":"40761","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine; thoracic, 3 views ","code_information":[{"code":"401","type":"RC"},{"code":"72072","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"NEUROLOGICAL; M < 25.85 ","code_information":[{"code":"158","type":"RC"},{"code":"A0604","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":24538.340,"maximum":28079.960,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":26815.090,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":25297.260,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":28079.960,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":26562.120,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":24538.340,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25550.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":25550.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":25550.230,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":25297.260,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":28079.960,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":28079.960,"methodology":"fee schedule"}]}]},{"description":"Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) ","code_information":[{"code":"45112","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"100","type":"RC"},{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18833.360,"maximum":18833.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18833.360,"methodology":"fee schedule"}]}]},{"description":"Neuro Muscular Dystrophy Dmd Seq Alys Bld/Saliva ","code_information":[{"code":"0218U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2210.630,"maximum":3418.500,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":2301.790,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":2392.950,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":2347.370,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":2324.580,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":2392.950,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":2324.580,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":3418.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":2392.950,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":2392.950,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":2210.630,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2734.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2301.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":2301.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":2301.790,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":3418.500,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":2392.950,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2324.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":2324.580,"methodology":"fee schedule"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; each additional 480 sq cm or part thereof (List separately in addi ","code_information":[{"code":"15016","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"REPLACEMENT OF LOWER EXT JOINT; M > 28.65 & M < 37 ","code_information":[{"code":"118","type":"RC"},{"code":"D0803","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17393.830,"maximum":19904.280,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":19007.690,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":17931.790,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":19904.280,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":18828.370,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":17393.830,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18111.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":18111.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":18111.100,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":17931.790,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":19904.280,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":19904.280,"methodology":"fee schedule"}]}]},{"description":"HFenestration semicircular canal ","code_information":[{"code":"481","type":"RC"},{"code":"69820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":10520.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater ","code_information":[{"code":"24071","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Vasopressin (antidiuretic hormone, ADH) ","code_information":[{"code":"84588","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":31.730,"maximum":40.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":31.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":31.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":40.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33.940,"methodology":"fee schedule"}]}]},{"description":"Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) ","code_information":[{"code":"360","type":"RC"},{"code":"64575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":47380.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37122.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39805.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":38400.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":47380.000,"methodology":"case rate"}]}]},{"description":"Interthoracoscapular amputation (forequarter) ","code_information":[{"code":"23900","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract ","code_information":[{"code":"47780","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Resection or transplantation of long tendon of biceps ","code_information":[{"code":"23440","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesionºs») ","code_information":[{"code":"21049","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulum ","code_information":[{"code":"27076","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Ileoscopy, through stoma; with transendoscopic balloon dilation ","code_information":[{"code":"44381","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiopharmaceutical therapy, by oral administration ","code_information":[{"code":"616","type":"RC"},{"code":"79005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":264.470,"maximum":264.470,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":264.470,"methodology":"fee schedule"}]}]},{"description":"Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) ","code_information":[{"code":"32506","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Selective enzymatic debridement, partial-thickness and/or full-thickness burn eschar, requiring anesthesia (ie, general anesthesia, moderate sedation), including patient monitoring, trunk, arms, legs; ","code_information":[{"code":"0974T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13205.200,"maximum":13205.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13205.200,"methodology":"fee schedule"}]}]},{"description":"Sex chromatin identification; peripheral blood smear, polymorphonuclear drumsticks ","code_information":[{"code":"302","type":"RC"},{"code":"88140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.990,"maximum":9.430,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.430,"methodology":"fee schedule"}]}]},{"description":"Oncology (urothelial), mrna, gene expression profiling by real-time quantitative pcr of 5 genes (mdk, hoxa13, cdc2 ºcdk1», igfbp5, and cxcr2), utilizing urine, algorithm incorporates age, sex, smoking ","code_information":[{"code":"0363U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":896.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"}]}]},{"description":"Valproic acid (dipropylacetic acid); total ","code_information":[{"code":"309","type":"RC"},{"code":"80164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.660,"maximum":15.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.890,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.540,"methodology":"fee schedule"}]}]},{"description":"Antibody; Aspergillus ","code_information":[{"code":"805461","type":"CDM"},{"code":"86606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.890,"maximum":26.210,"gross_charge":303.50,"discounted_cash":303.50,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":15.200,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":15.500,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":15.350,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":26.210,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":15.350,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":22.580,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":14.600,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":18.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15.200,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":15.200,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":15.200,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":12.890,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":22.580,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":15.050,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":15.350,"methodology":"fee schedule"}]}]},{"description":"Injection, bortezomib, 0.1 mg ","drug_information":{"unit":3.500000000000000e+000,"type":"ME"},"code_information":[{"code":"636","type":"RC"},{"code":"639118","type":"CDM"},{"code":"J9041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.760,"maximum":5.760,"gross_charge":81.95,"discounted_cash":81.95,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.760,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC ","code_information":[{"code":"013","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":22109.750,"maximum":22109.750,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22109.750,"methodology":"fee schedule"}]}]},{"description":"Relese, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Tracheostoma revision; complex, with flap rotation ","code_information":[{"code":"31614","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION ","code_information":[{"code":"0453","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12777.170,"maximum":19165.760,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":12777.170,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":13032.710,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":19165.760,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":12777.170,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":12777.170,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":12777.170,"methodology":"fee schedule"}]}]},{"description":"Angiography, internal mammary, radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"75756","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":72.680,"maximum":88.390,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":72.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":82.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":72.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":88.390,"methodology":"fee schedule"}]}]},{"description":"Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes ºMELAS», myoclonic epilepsy with ragged-red fibers ºMERFF», neuropathy, ataxi ","code_information":[{"code":"81460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1158.300,"maximum":1930.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":1158.300,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1299.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":1158.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":1158.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":1158.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":1158.300,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":1351.350,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":1325.610,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":1312.740,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1351.350,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":1814.670,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":1312.740,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":1930.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1351.350,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1351.350,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":1248.390,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1544.400,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1299.870,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":1299.870,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":1299.870,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":1930.500,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1351.350,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1312.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":1287.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":1312.740,"methodology":"fee schedule"}]}]},{"description":"Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells ","code_information":[{"code":"307","type":"RC"},{"code":"88235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":150.300,"maximum":177.350,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":150.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":177.350,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy ","code_information":[{"code":"361","type":"RC"},{"code":"44208","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":11066.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization ","code_information":[{"code":"42971","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"64859","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC ","code_information":[{"code":"904","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15660.560,"maximum":16952.160,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":16952.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":15660.560,"methodology":"fee schedule"}]}]},{"description":"PLEURAL EFFUSION WITH CC ","code_information":[{"code":"122","type":"RC"},{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8617.120,"maximum":8617.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8617.120,"methodology":"fee schedule"}]}]},{"description":"Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure) ","code_information":[{"code":"11201","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra) ","code_information":[{"code":"51845","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm ","code_information":[{"code":"12006","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Replacement, pulmonary valve ","code_information":[{"code":"33475","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Alpha-1-antitrypsin; total ","code_information":[{"code":"310","type":"RC"},{"code":"82103","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.440,"maximum":15.860,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.860,"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":39805.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37122.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39805.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":130.00,"standard_charge_algorithm":"Reimbursement will be 130% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. Zero instances of this service in the last 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":"AllPayerAppendix","standard_charge_dollar":30900.000,"methodology":"case rate"}]}]},{"description":"Excision external ear; complete amputation ","code_information":[{"code":"69120","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, skull; less than 4 views ","code_information":[{"code":"618","type":"RC"},{"code":"70250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, salivary gland for calculus ","code_information":[{"code":"351","type":"RC"},{"code":"70380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Brain imaging, less than 4 static views; with vascular flow ","code_information":[{"code":"340","type":"RC"},{"code":"78601","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":271.370,"maximum":848.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":271.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":307.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":271.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":312.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (Kidd blood group) genotyping (JK), gene analysis, SLC14A1 (solute carrier family 14 member 1) gene promoter, exon 9 ","code_information":[{"code":"0192U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement ","code_information":[{"code":"29846","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT MALIGNANCY ","code_information":[{"code":"4611","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4004.780,"maximum":6007.170,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":4004.780,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":4084.880,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":6007.170,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":4004.780,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":4004.780,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":4004.780,"methodology":"fee schedule"}]}]},{"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":"0454U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1181.400,"maximum":1490.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1181.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1389.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1181.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1389.880,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1263.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1490.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1263.530,"methodology":"fee schedule"}]}]},{"description":"Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis ","code_information":[{"code":"400","type":"RC"},{"code":"75898","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":236.190,"maximum":287.250,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":236.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":267.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":236.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":287.250,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10717.970,"maximum":10717.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10717.970,"methodology":"fee schedule"}]}]},{"description":"Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"49424","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"167","type":"RC"},{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14376.460,"maximum":14376.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14376.460,"methodology":"fee schedule"}]}]},{"description":"Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendon ","code_information":[{"code":"26352","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less ","code_information":[{"code":"12001","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Red cell antigen (Yt blood group) genotyping (YT), gene analysis, ACHE (acetylcholinesterase (Cartwright blood group)) exon 2 ","code_information":[{"code":"0201U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":173.160,"maximum":218.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":218.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Cystorrhaphy, suture of bladder wound, injury or rupture; simple ","code_information":[{"code":"51860","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Oncology (bladder),methylated PENK DNA detection by linear target enrichment-quantitative methylation-specific real-time PCR (LTR-qMSP),urine reported as likelihood of bladder cancer ","code_information":[{"code":"0452U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":192.000,"maximum":226.560,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":192.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":226.560,"methodology":"fee schedule"}]}]},{"description":"Anti-phosphatidylserine (phospholipid) antibody ","code_information":[{"code":"307","type":"RC"},{"code":"86148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.030,"maximum":18.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.070,"methodology":"fee schedule"}]}]},{"description":"Receptor assay; non-endocrine (specify receptor) ","code_information":[{"code":"306","type":"RC"},{"code":"84238","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.190,"maximum":43.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":34.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":34.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":40.230,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":36.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":43.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36.570,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy, radical, complete; ","code_information":[{"code":"481","type":"RC"},{"code":"56633","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure when performed ","code_information":[{"code":"32655","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns which disrupt the pelvic ring, unilateral or bilateral, (includes ilium, sacroiliac joint and ","code_information":[{"code":"369","type":"RC"},{"code":"G0413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Biopsy, muscle; deep ","code_information":[{"code":"20205","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"NEUROLOGICAL; M > 47.75 ","code_information":[{"code":"148","type":"RC"},{"code":"C0601","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":15505.310,"maximum":17743.180,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":16943.940,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":15984.850,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":17743.180,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":16784.090,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":15505.310,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16144.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":16144.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":16144.700,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":15984.850,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":17743.180,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":17743.180,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"404","type":"RC"},{"code":"72130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators ","code_information":[{"code":"401","type":"RC"},{"code":"77610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.600,"maximum":682.600,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"Vermilionectomy (lip shave), with mucosal advancement ","code_information":[{"code":"369","type":"RC"},{"code":"40500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4344.050,"maximum":4702.320,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":4702.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":4344.050,"methodology":"fee schedule"}]}]},{"description":"REPAIR OF SCLERAL STAPHYLOMA; WITHOUT GRAFT ","code_information":[{"code":"499","type":"RC"},{"code":"66220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greater ","code_information":[{"code":"26111","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33381.030,"maximum":33381.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33381.030,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach ","code_information":[{"code":"63301","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Suture or repair of testicular injury ","code_information":[{"code":"367","type":"RC"},{"code":"54670","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography, internal mammary, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75756","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":160.250,"maximum":194.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":160.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":181.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":160.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":194.890,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas ","code_information":[{"code":"402","type":"RC"},{"code":"78801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":442.440,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":442.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Chemodenervation of trunk muscle(s); 6 or more muscles ","code_information":[{"code":"64647","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Esophagogastric fundoplasty partial or complete; thoracotomy ","code_information":[{"code":"43328","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code ","code_information":[{"code":"324","type":"RC"},{"code":"77003","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":107.900,"maximum":131.230,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":107.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":122.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":107.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":131.230,"methodology":"fee schedule"}]}]},{"description":"Lipoprotein, direct measurement; VLDL cholesterol ","code_information":[{"code":"304","type":"RC"},{"code":"83719","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.920,"maximum":15.040,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.030,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.750,"methodology":"fee schedule"}]}]},{"description":"Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use ","code_information":[{"code":"636","type":"RC"},{"code":"90733","type":"CPT"},{"code":"917735","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":192.450,"maximum":192.450,"gross_charge":909.00,"discounted_cash":909.00,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":192.450,"methodology":"fee schedule"}]}]},{"description":"ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":40702.280,"maximum":40702.280,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":40702.280,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":10852.700,"maximum":10852.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10852.700,"methodology":"fee schedule"}]}]},{"description":"Urography, antegrade, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"74425","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":156.240,"maximum":190.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":156.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":177.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":156.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":190.010,"methodology":"fee schedule"}]}]},{"description":"Elevation of depressed skull fracture; compound or comminuted, extradural ","code_information":[{"code":"62005","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Creation of shunt; ventriculo-peritoneal, -pleural, other terminus ","code_information":[{"code":"480","type":"RC"},{"code":"62223","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Biopsy of epididymis, needle ","code_information":[{"code":"361","type":"RC"},{"code":"54800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Osteotomy, tarsal bones, other than calcaneus or talus; ","code_information":[{"code":"28304","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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, ankle; 2 views ","code_information":[{"code":"323","type":"RC"},{"code":"73600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.990,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":45.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":51.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":45.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":55.150,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":40.920,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":35.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Insertion of pacemaker pulse generator only; with existing single lead ","code_information":[{"code":"33212","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9657.000,"maximum":40306.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12517.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14199.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12517.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15225.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14688.000,"methodology":"case rate"}]}]},{"description":"Dacryocystography, nasolacrimal duct, radiological supervision and interpretation ","code_information":[{"code":"401","type":"RC"},{"code":"70170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"200","type":"RC"},{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13712.050,"maximum":13712.050,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13712.050,"methodology":"fee schedule"}]}]},{"description":"Oph Age-related Mac Degeneration Alys 3 Gen Vrnt ","code_information":[{"code":"0205U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":43.950,"maximum":55.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":51.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":51.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":55.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":47.000,"methodology":"fee schedule"}]}]},{"description":"Intravascular imaging of intracranial cerebral vessels using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention, including all associated radiological supe ","code_information":[{"code":"0986T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MC ","code_information":[{"code":"173","type":"RC"},{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12520.830,"maximum":12520.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12520.830,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC Pediatric","code_information":[{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28417.960,"maximum":39784.060,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":39784.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":39784.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":39784.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":39784.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":28417.960,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, femur or knee ","code_information":[{"code":"27599","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE ","code_information":[{"code":"200","type":"RC"},{"code":"790","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":43935.890,"maximum":43935.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":43935.890,"methodology":"fee schedule"}]}]},{"description":"Rare DS Whl Gen & Mitochdrl DNA Seq Alys Proband ","code_information":[{"code":"0212U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5310.940,"maximum":8212.800,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":5529.950,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":5748.960,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":5639.460,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5584.700,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":5748.960,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":5584.700,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":8212.800,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":5748.960,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":5748.960,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":5310.940,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":6570.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5529.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":5529.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":5529.950,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":8212.800,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5748.960,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5584.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":5475.200,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":5584.700,"methodology":"fee schedule"}]}]},{"description":"Osteoplasty, facial bones; reduction ","code_information":[{"code":"21209","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH CC ","code_information":[{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":32592.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":29669.580,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":11702.940,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":29669.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":29669.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":29669.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":21192.560,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":26794.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30394.830,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":11934.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":26794.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32592.000,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":14483.840,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":11818.810,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":9849.010,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":9849.010,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":11818.810,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":11818.810,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14937.890,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":12050.550,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16140.800,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":12050.550,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":11239.460,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":12105.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11702.940,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":11702.940,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":11702.940,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":11587.070,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":11587.070,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":11587.070,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":15242.740,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":15967.110,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":13159.940,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":15815.450,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":12113.830,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":12050.550,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":14633.030,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":12050.550,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":14937.890,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":17380.600,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12166.420,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":11587.070,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":15242.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13596.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11343.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":11587.070,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":11587.070,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":11818.810,"methodology":"fee schedule"}]}]},{"description":"Flecainide ","code_information":[{"code":"301","type":"RC"},{"code":"80181","type":"CPT"},{"code":"804822","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":17.430,"maximum":22.000,"gross_charge":512.75,"discounted_cash":512.75,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.640,"methodology":"fee schedule"}]}]},{"description":"Continent ileostomy (Kock procedure) (separate procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"44316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"81180","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"11306","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"New Technology - Level 40 ","code_information":[{"code":"1577","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":19137.020,"maximum":29593.330,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":19926.180,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":20320.760,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20715.330,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":20123.470,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19728.890,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":20715.330,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20715.330,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":19137.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19926.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19926.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19926.180,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":19728.890,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":19728.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19728.890,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":29593.330,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20715.330,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":19728.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20123.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":19728.890,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":20123.470,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, glenohumeral joint; ","code_information":[{"code":"23800","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venous thrombosis imaging, venogram; bilateral ","code_information":[{"code":"349","type":"RC"},{"code":"78458","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":260.750,"maximum":848.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":260.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":295.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":260.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":300.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, pelvis; complete, minimum of 3 views ","code_information":[{"code":"341","type":"RC"},{"code":"72190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical ","code_information":[{"code":"499","type":"RC"},{"code":"54050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Amputation, thigh, through femur, any level; open, circular (guillotine) ","code_information":[{"code":"27592","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Therapeutic drug monitoring, medications specific to pain, depression, and anxiety, LC-MS/MS, plasma, 110 or more drugs or substances, qualitative and quantitative therpeutic minimally effective range ","code_information":[{"code":"0519U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":230.870,"maximum":291.370,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":230.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":271.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":230.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":271.610,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":291.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":246.920,"methodology":"fee schedule"}]}]},{"description":"Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) ","code_information":[{"code":"362","type":"RC"},{"code":"52318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0DL73CZ","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Radiologic examination; sternum, minimum of 2 views ","code_information":[{"code":"401","type":"RC"},{"code":"71120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Osteochondral allograft, knee, open ","code_information":[{"code":"27415","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"314","type":"RC"},{"code":"87332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.980,"maximum":14.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITHOUT CC/MCC Pediatric","code_information":[{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8888.460,"maximum":12443.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":12443.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":12443.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":12443.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":12443.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":8888.460,"methodology":"fee schedule"}]}]},{"description":"Osteotomy; radius AND ulna ","code_information":[{"code":"25365","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier ","code_information":[{"code":"0006M","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":150.000,"maximum":177.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":177.000,"methodology":"fee schedule"}]}]},{"description":"Removal of implanted material, posterior segment; extraocular ","code_information":[{"code":"360","type":"RC"},{"code":"67120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Pulmonary disease (idiopathic pulmonary fibrosis ºIPF»), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positi ","code_information":[{"code":"302","type":"RC"},{"code":"81554","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5142.500,"maximum":6383.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5142.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6050.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5142.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6050.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5409.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6383.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5500.000,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when perfor ","code_information":[{"code":"362","type":"RC"},{"code":"52284","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nfct Agent HIV Trgt Viral Next-Gnrj Seq Alys Alg ","code_information":[{"code":"0219U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":677.880,"maximum":855.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":677.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":797.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":677.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":797.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":725.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":855.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":725.000,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32881.310,"maximum":32881.310,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":32881.310,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study ","code_information":[{"code":"323","type":"RC"},{"code":"74230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":139.690,"maximum":401.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":168.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":191.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":168.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":205.380,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":197.010,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":139.690,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC Pediatric","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26321.470,"maximum":36849.060,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":36849.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":36849.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":36849.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":36849.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":26321.470,"methodology":"fee schedule"}]}]},{"description":"Cerebrospinal fluid leakage detection and localization ","code_information":[{"code":"615","type":"RC"},{"code":"78650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.470,"maximum":1540.470,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1540.470,"methodology":"fee schedule"}]}]},{"description":"Neurology (mild cognitive impairment), analysis of b-amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative ","code_information":[{"code":"0358U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":243.570,"maximum":307.390,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":243.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":286.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":243.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":286.550,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":260.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":307.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":260.500,"methodology":"fee schedule"}]}]},{"description":"Biopsy, muscle; deep ","code_information":[{"code":"20205","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"123","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7765.230,"maximum":7765.230,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7765.230,"methodology":"fee schedule"}]}]},{"description":"PANCREAS TRANSPLANT ","code_information":[{"code":"010","type":"MS-DRG"},{"code":"134","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":52719.950,"maximum":52719.950,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":52719.950,"methodology":"fee schedule"}]}]},{"description":"Esophagojejunostomy (without total gastrectomy); thoracic approach ","code_information":[{"code":"43341","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11970.490,"maximum":11970.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11970.490,"methodology":"fee schedule"}]}]},{"description":"PMS2 (PMS1 homolog 2, mismatch repair system component) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (List separately in addition to code for primary procedur ","code_information":[{"code":"0161U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":264.490,"maximum":333.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":264.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":311.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":264.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":311.170,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":333.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":282.880,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope ","code_information":[{"code":"31526","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus ","code_information":[{"code":"31259","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection) ","code_information":[{"code":"22858","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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"},{"code":"172","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":12711.890,"maximum":12711.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12711.890,"methodology":"fee schedule"}]}]},{"description":"Injection, epoetin alfa, (for non-esrd use), 1000 units ","code_information":[{"code":"636","type":"RC"},{"code":"J0885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":16.640,"maximum":16.640,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.640,"methodology":"fee schedule"}]}]},{"description":"Excision, sacral pressure ulcer, with skin flap closure; with ostectomy ","code_information":[{"code":"15935","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacra ","code_information":[{"code":"22512","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and im ","code_information":[{"code":"37192","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture repair of aorta or great vessels; with shunt bypass ","code_information":[{"code":"33321","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"213","type":"RC"},{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7621.230,"maximum":7621.230,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7621.230,"methodology":"fee schedule"}]}]},{"description":"Drainage abscess or hematoma, nasal, internal approach ","code_information":[{"code":"30000","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"111","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7323.250,"maximum":7323.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7323.250,"methodology":"fee schedule"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITH CC/MCC ","code_information":[{"code":"052","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":14478.390,"maximum":14478.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14478.390,"methodology":"fee schedule"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker) ","code_information":[{"code":"67041","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance angiography, head; with contrast material(s) ","code_information":[{"code":"342","type":"RC"},{"code":"70545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Excision of ganglion, wrist (dorsal or volar); recurrent ","code_information":[{"code":"25112","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted laparoscopic procedure, liver ","code_information":[{"code":"369","type":"RC"},{"code":"47379","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"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":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1770.480,"maximum":2089.170,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1770.480,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2089.170,"methodology":"fee schedule"}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm ","code_information":[{"code":"12006","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards o ","code_information":[{"code":"305","type":"RC"},{"code":"82270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.100,"maximum":5.170,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.380,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage, shoulder area; infected bursa ","code_information":[{"code":"23031","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arrest, epiphyseal (epiphysiodesis), open; distal tibia ","code_information":[{"code":"27730","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Gliadin (deamidated) (DGP) antibody, each immunoglobulin (Ig) class ","code_information":[{"code":"307","type":"RC"},{"code":"86258","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.780,"maximum":14.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.530,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with irrigation and evacuation of multiple obstructing clots ","code_information":[{"code":"360","type":"RC"},{"code":"52001","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC Pediatric","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19487.090,"maximum":27281.190,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":27281.190,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":27281.190,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":27281.190,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":27281.190,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":19487.090,"methodology":"fee schedule"}]}]},{"description":"Hepatitis B surface antibody (HBsAb) ","code_information":[{"code":"312","type":"RC"},{"code":"86706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.740,"maximum":12.670,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.670,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views ","code_information":[{"code":"615","type":"RC"},{"code":"73522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Level 1 Imaging with Cont ","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":152.410,"maximum":235.690,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":158.700,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":161.840,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":164.980,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":160.270,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":157.130,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":164.980,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":164.980,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":152.410,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":158.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":158.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":158.700,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":157.130,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":157.130,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":157.130,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":235.690,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":164.980,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":157.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":160.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":157.130,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":160.270,"methodology":"fee schedule"}]}]},{"description":"SKIN DEBRIDEMENT WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9737.760,"maximum":9737.760,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9737.760,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of greater trochanteric fracture, without manipulation ","code_information":[{"code":"27246","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Unlisted laparoscopy procedure, biliary tract ","code_information":[{"code":"47579","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Osteoplasty, lengthening, metacarpal or phalanx ","code_information":[{"code":"26568","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, age 12 years or older ","code_information":[{"code":"31552","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring laminectomy ","code_information":[{"code":"481","type":"RC"},{"code":"63741","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC ","code_information":[{"code":"125","type":"MS-DRG"},{"code":"209","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7039.530,"maximum":7039.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7039.530,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH PTCA WITHOUT MCC ","code_information":[{"code":"206","type":"RC"},{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":44784.930,"maximum":44784.930,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":44784.930,"methodology":"fee schedule"}]}]},{"description":"Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate ","code_information":[{"code":"15773","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure, endoscopic ","code_information":[{"code":"33509","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted cardiovascular procedure, diagnostic nuclear medicine ","code_information":[{"code":"619","type":"RC"},{"code":"78499","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITH MCC One Day Stay","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11859.290,"maximum":11859.290,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11859.290,"methodology":"fee schedule"}]}]},{"description":"Susceptibility studies, antimicrobial agent; carbapenem resistance genes (eg, blaKPC, blaNDM, blaVIM, blaOXA-48, blaIMP), amplified probe technique, per isolate ","code_information":[{"code":"312","type":"RC"},{"code":"87183","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":41.410,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"110","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6713.030,"maximum":6713.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6713.030,"methodology":"fee schedule"}]}]},{"description":"Biopsy, prostate, transrectal, ultrasound-guided (ie, sextant) with MRI-fusion-guidance, first targeted lesion ","code_information":[{"code":"55708","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and h ","code_information":[{"code":"17315","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7562.780,"maximum":7562.780,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7562.780,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS ","code_information":[{"code":"065","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8768.250,"maximum":8768.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8768.250,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16756.740,"maximum":16756.740,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16756.740,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA WITH BRAIN OR SPINAL CODE IN ","code_information":[{"code":"024","type":"RC"},{"code":"C1804","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":27247.420,"maximum":27247.420,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":27247.420,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with initial transurethral anterior prostate commissurotomy with a nondrug-coated balloon catheter followed by therapeutic drug delivery into the prostate by a drug-coated balloon ca ","code_information":[{"code":"52443","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29967.780,"maximum":29967.780,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":29967.780,"methodology":"fee schedule"}]}]},{"description":"Hepatectomy, resection of liver; total right lobectomy ","code_information":[{"code":"360","type":"RC"},{"code":"47130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC One Day Stay","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D194JA","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3296.000,"maximum":3296.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3296.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Platelet survival study ","code_information":[{"code":"402","type":"RC"},{"code":"78191","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":222.290,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Renal autotransplantation, reimplantation of kidney ","code_information":[{"code":"481","type":"RC"},{"code":"50380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":26570.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J3304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":39.950,"maximum":39.950,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":39.950,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; carotid-subclavian or subclavian-carotid ","code_information":[{"code":"35506","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Repair of patent ductus arteriosus; by division, 18 years and older ","code_information":[{"code":"33824","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venography, epidural, radiological supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"75872","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":175.190,"maximum":729.550,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":175.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":729.550,"methodology":"fee schedule"}]}]},{"description":"Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) ","code_information":[{"code":"30465","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Manual wheelchair accessory, adapter for amputee, each ","code_information":[{"code":"E0959","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":53.230,"maximum":82.320,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":55.430,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":56.530,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":57.620,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":55.980,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":54.880,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":57.620,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":57.620,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":53.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":55.430,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":55.430,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":55.430,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":54.880,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":54.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":54.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":53.230,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":82.320,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":57.620,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":54.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":55.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":54.880,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":55.980,"methodology":"fee schedule"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) ","code_information":[{"code":"33365","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Laminectomy with section of spinal accessory nerve ","code_information":[{"code":"480","type":"RC"},{"code":"63191","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"Q5136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":60.690,"maximum":60.690,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":60.690,"methodology":"fee schedule"}]}]},{"description":"Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use ","code_information":[{"code":"343","type":"RC"},{"code":"90723","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.310,"maximum":285.310,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":285.310,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (cromlton blood group) genotyping (CROM), gene analysis, CD55 (CD55 molecule) exons 1-10 ","code_information":[{"code":"0182U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":292.310,"maximum":452.030,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":310.390,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":307.380,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":307.380,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":452.030,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":292.310,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":361.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":452.030,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":307.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":307.380,"methodology":"fee schedule"}]}]},{"description":"Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesionºs») ","code_information":[{"code":"21046","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; not otherwise specified ","code_information":[{"code":"304","type":"RC"},{"code":"87899","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.030,"maximum":18.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.070,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement ","code_information":[{"code":"490","type":"RC"},{"code":"50947","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg ","code_information":[{"code":"J1566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":78.580,"maximum":213.310,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":92.220,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":93.240,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":137.120,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":209.040,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":78.580,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":213.310,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":91.410,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":204.780,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":209.040,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":213.310,"methodology":"fee schedule"}]}]},{"description":"Oncology (bladder), analysis of 10 protein biomarkers by immunoassays, urine, algorithm reported as a probability of bladder cancer ","code_information":[{"code":"0365U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":838.700,"maximum":1058.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":838.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":986.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":838.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":986.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1058.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":897.000,"methodology":"fee schedule"}]}]},{"description":"HLA typing; A, B, or C, multiple antigens ","code_information":[{"code":"300","type":"RC"},{"code":"86813","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":54.230,"maximum":68.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":54.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":63.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":54.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":63.800,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":58.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":68.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":58.000,"methodology":"fee schedule"}]}]},{"description":"Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); each separate/additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"11103","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventri ","code_information":[{"code":"61864","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (colorectal cancer), eval for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, IPK3CA, SMAD4, and TP53, and methylation markers, multiplex quantitative polymerase chain reaction (qPCR), circulatin ","code_information":[{"code":"0368U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":389.690,"maximum":491.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":389.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":458.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":389.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":458.460,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":491.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":34333.440,"maximum":34333.440,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":34333.440,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":39179.580,"maximum":39179.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":39179.580,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, oviduct, ovary ","code_information":[{"code":"58679","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":14369.190,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5690.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":7390.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2984.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13794.420,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Impression and custom preparation; definitive obturator prosthesis ","code_information":[{"code":"21080","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":36212.400,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":32965.350,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":12841.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":32965.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":32965.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":32965.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":23546.680,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":29770.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":33771.170,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":13096.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":29770.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":36212.400,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":15893.240,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":12968.880,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":10807.400,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":10807.400,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":12968.880,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12968.880,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":15856.840,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":13223.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17933.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":13223.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":12333.150,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":13450.320,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12841.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":12841.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":12841.740,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":12714.590,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":12714.590,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":12714.590,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":16180.450,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":16949.380,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":13969.520,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":16788.390,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":12859.060,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":13223.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":15533.230,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":13223.170,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":15856.840,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":19071.890,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13350.320,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":12714.590,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":16180.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13596.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12447.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":12714.590,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":12714.590,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":12968.880,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC ","code_information":[{"code":"129","type":"RC"},{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Proctectomy; partial resection of rectum, transabdominal approach ","code_information":[{"code":"361","type":"RC"},{"code":"45111","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan ","code_information":[{"code":"611","type":"RC"},{"code":"77338","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":431.960,"maximum":431.960,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":431.960,"methodology":"fee schedule"}]}]},{"description":"Omental flap, intra-abdominal (List separately in addition to code for primary procedure) ","code_information":[{"code":"49905","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6315.830,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Aortography, abdominal, by serialography, radiological supervision and interpretation ","code_information":[{"code":"403","type":"RC"},{"code":"75625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"121","type":"RC"},{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9320.730,"maximum":9320.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9320.730,"methodology":"fee schedule"}]}]},{"description":"Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) ","code_information":[{"code":"28270","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14597.440,"maximum":14597.440,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14597.440,"methodology":"fee schedule"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":36772.200,"maximum":36772.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":36772.200,"methodology":"fee schedule"}]}]},{"description":"Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations ","code_information":[{"code":"350","type":"RC"},{"code":"78414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"SPLENIC PROCEDURES WITH CC ","code_information":[{"code":"116","type":"RC"},{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21593.620,"maximum":21593.620,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21593.620,"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":"305","type":"RC"},{"code":"87337","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.200,"maximum":14.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.980,"methodology":"fee schedule"}]}]},{"description":"Pretreatment of serum for use in RBC antibody identification; by dilution ","code_information":[{"code":"306","type":"RC"},{"code":"86976","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.070,"maximum":27.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":27.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.670,"methodology":"fee schedule"}]}]},{"description":"Injection, argatroban (accord), not therapeutically equivalent to j0883, 1 mg (for non-esrd use) ","code_information":[{"code":"636","type":"RC"},{"code":"J0891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.910,"maximum":3.910,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.910,"methodology":"fee schedule"}]}]},{"description":"AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence ","code_information":[{"code":"306","type":"RC"},{"code":"81173","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":281.760,"maximum":355.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":281.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":331.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":281.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":331.490,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":355.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":301.350,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; phalanx of toe ","code_information":[{"code":"28175","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Zinc ","code_information":[{"code":"84630","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10.650,"maximum":13.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.390,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"822","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10149.090,"maximum":10149.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10149.090,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"172","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8794.630,"maximum":8794.630,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8794.630,"methodology":"fee schedule"}]}]},{"description":"Ipratropium bromide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram ","code_information":[{"code":"J7644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.350,"maximum":0.690,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":0.400,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":0.470,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":0.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":0.350,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":0.460,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26006.320,"maximum":26006.320,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26006.320,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion ","code_information":[{"code":"612","type":"RC"},{"code":"76978","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"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, popliteal ar ","code_information":[{"code":"35151","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":37120.070,"maximum":37120.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":37120.070,"methodology":"fee schedule"}]}]},{"description":"Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral ","code_information":[{"code":"362","type":"RC"},{"code":"69705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy, flexible; diagnostic ","code_information":[{"code":"31575","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"209","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13195.930,"maximum":13195.930,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13195.930,"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":2484.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Removal of pancreatic calculus ","code_information":[{"code":"369","type":"RC"},{"code":"48020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21054.680,"maximum":21054.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21054.680,"methodology":"fee schedule"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC ","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":114880.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":104579.550,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":37586.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":104579.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":104579.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":104579.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":74699.680,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":94443.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":107135.910,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":38331.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":94443.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":114880.500,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":46518.330,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":37958.950,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":31632.460,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":31632.460,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":37958.950,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":37958.950,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":52402.770,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":38703.250,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":56893.200,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":38703.250,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":36098.220,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":42669.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":37586.810,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":37586.810,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":37586.810,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":37214.660,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":37214.660,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":37214.660,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":53472.210,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":56013.330,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":46165.660,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":55481.310,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":42495.860,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":38703.250,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":51333.320,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":38703.250,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":52402.770,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":55821.990,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":39075.390,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":37214.660,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":53472.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13596.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":36433.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":37214.660,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":37214.660,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":37958.950,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor XIII (fibrin stabilizing), screen solubility ","code_information":[{"code":"300","type":"RC"},{"code":"85291","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.520,"maximum":10.750,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10.020,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.110,"methodology":"fee schedule"}]}]},{"description":"Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary ","code_information":[{"code":"33419","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair blood vessel, direct; hand, finger ","code_information":[{"code":"35207","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) ","code_information":[{"code":"303","type":"RC"},{"code":"81230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":163.450,"maximum":206.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":163.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":192.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":163.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":192.290,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":174.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":206.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":174.810,"methodology":"fee schedule"}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endosco ","code_information":[{"code":"361","type":"RC"},{"code":"66984","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3906.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3245.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3869.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2987.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Management of liver hemorrhage; simple suture of liver wound or injury ","code_information":[{"code":"360","type":"RC"},{"code":"47350","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, vascular surgery ","code_information":[{"code":"361","type":"RC"},{"code":"37799","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"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"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":9764.400,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":9569.110,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":9764.400,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":9373.820,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":9569.110,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":9764.400,"methodology":"fee schedule"}]}]},{"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":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC ","code_information":[{"code":"124","type":"RC"},{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16299.090,"maximum":16299.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16299.090,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumb ","code_information":[{"code":"63090","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater ","code_information":[{"code":"24073","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, osseous survey, infant ","code_information":[{"code":"610","type":"RC"},{"code":"77076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J1954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1519.340,"maximum":1519.340,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1519.340,"methodology":"fee schedule"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18578.150,"maximum":18578.150,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18578.150,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy with biopsy; metacarpophalangeal joint, each ","code_information":[{"code":"26105","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6700.910,"maximum":6700.910,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6700.910,"methodology":"fee schedule"}]}]},{"description":"Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, ","code_information":[{"code":"32994","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"53520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body in muscle or tendon sheath; simple ","code_information":[{"code":"20520","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed ","code_information":[{"code":"481","type":"RC"},{"code":"49412","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27047.840,"maximum":27047.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27047.840,"methodology":"fee schedule"}]}]},{"description":"MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 ","code_information":[{"code":"319","type":"RC"},{"code":"81339","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":185.200,"maximum":218.540,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":218.540,"methodology":"fee schedule"}]}]},{"description":"Trimethylamine/trimethylamine N-oxide (TMA/TMAO) profile, tandem mass spectrometry (MS/MS), urine, with algorithmic analysis and interpretive report ","code_information":[{"code":"0256U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":149.550,"maximum":188.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":149.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":175.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":149.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":175.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":159.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":188.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":159.950,"methodology":"fee schedule"}]}]},{"description":"Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in addition to code for primary procedure) ","code_information":[{"code":"33929","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Opponensplasty; hypothenar muscle transfer ","code_information":[{"code":"26494","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15318.160,"maximum":15318.160,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15318.160,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy with biopsy; intertarsal or tarsometatarsal joint ","code_information":[{"code":"28050","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Molecular pathology procedure; physician interpretation and report ","code_information":[{"code":"312","type":"RC"},{"code":"G0452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.670,"maximum":3.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.140,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique ","code_information":[{"code":"43251","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19097.130,"maximum":19097.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19097.130,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC ","code_information":[{"code":"144","type":"RC"},{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8697.680,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8697.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Venous anastomosis, open; splenorenal, proximal ","code_information":[{"code":"361","type":"RC"},{"code":"37180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Wedging of clubfoot cast ","code_information":[{"code":"29750","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Incision and drainage, forearm and/or wrist; bursa ","code_information":[{"code":"25031","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) ","code_information":[{"code":"311","type":"RC"},{"code":"88248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":147.190,"maximum":204.340,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":147.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":173.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":147.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":173.170,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":173.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":204.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":173.170,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study ","code_information":[{"code":"329","type":"RC"},{"code":"74221","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.410,"maximum":52.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":49.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":52.800,"methodology":"fee schedule"}]}]},{"description":"Prednisone, immediate release or delayed release, oral, 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J7512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.020,"maximum":0.020,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.020,"methodology":"fee schedule"}]}]},{"description":"Injection, intralesional; up to and including 7 lesions ","code_information":[{"code":"11900","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency ","code_information":[{"code":"481","type":"RC"},{"code":"60660","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":11066.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"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, radial or ul ","code_information":[{"code":"35045","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical therapy, unlisted procedure ","code_information":[{"code":"402","type":"RC"},{"code":"79999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":264.470,"maximum":264.470,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":264.470,"methodology":"fee schedule"}]}]},{"description":"Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed ","code_information":[{"code":"57240","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of foreign body in muscle or tendon sheath; deep or complicated ","code_information":[{"code":"20525","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) ","code_information":[{"code":"301","type":"RC"},{"code":"81363","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":189.240,"maximum":238.830,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":189.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":222.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":189.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":222.640,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":202.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":238.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":202.400,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12731.130,"maximum":12731.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12731.130,"methodology":"fee schedule"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC ","code_information":[{"code":"211","type":"RC"},{"code":"355","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11154.250,"maximum":11154.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11154.250,"methodology":"fee schedule"}]}]},{"description":"Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple ","code_information":[{"code":"42960","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy, flexible; with removal of prostatic urethral scaffold ","code_information":[{"code":"0943T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Replacement, tricuspid valve, with cardiopulmonary bypass ","code_information":[{"code":"33465","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"122","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7167.840,"maximum":7167.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7167.840,"methodology":"fee schedule"}]}]},{"description":"Urea breath test, C-14 (isotopic); analysis ","code_information":[{"code":"307","type":"RC"},{"code":"78268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":94.410,"maximum":111.400,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":94.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":111.400,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14176.140,"maximum":14176.140,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14176.140,"methodology":"fee schedule"}]}]},{"description":"Injection, dobutamine hydrochloride, per 250 mg ","code_information":[{"code":"J1250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7.910,"maximum":13.380,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":11.570,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":9.100,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":13.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":7.910,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":8.920,"methodology":"fee schedule"}]}]},{"description":"Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"481","type":"RC"},{"code":"C7530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH CC ","code_information":[{"code":"071","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8880.170,"maximum":8880.170,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8880.170,"methodology":"fee schedule"}]}]},{"description":"Unlisted diagnostic radiographic procedure ","code_information":[{"code":"404","type":"RC"},{"code":"76499","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with rhizotomy; more than 2 segments ","code_information":[{"code":"63190","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":19440.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D198KB","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Laparoscopy, surgical; gastrostomy, without construction of gastric tube (eg, Stamm procedure) (separate procedure) ","code_information":[{"code":"43653","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"61800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Androsterone ","code_information":[{"code":"311","type":"RC"},{"code":"82160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.550,"maximum":30.150,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.150,"methodology":"fee schedule"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH CC ","code_information":[{"code":"120","type":"RC"},{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15214.090,"maximum":15214.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15214.090,"methodology":"fee schedule"}]}]},{"description":"Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Suture of each additional nerve, hand or foot (List separately in addition to code for primary procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"64837","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"130","type":"RC"},{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":61471.950,"maximum":61471.950,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":61471.950,"methodology":"fee schedule"}]}]},{"description":"Excision of synovial cyst of popliteal space (eg, Baker's cyst) ","code_information":[{"code":"27345","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pulmonary artery embolectomy; with cardiopulmonary bypass ","code_information":[{"code":"33910","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique ","code_information":[{"code":"306","type":"RC"},{"code":"87561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.810,"maximum":41.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) ","code_information":[{"code":"32668","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11066.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) ","code_information":[{"code":"319","type":"RC"},{"code":"81224","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":168.750,"maximum":199.130,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":199.130,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach ","code_information":[{"code":"42720","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"144","type":"RC"},{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8768.960,"maximum":8768.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8768.960,"methodology":"fee schedule"}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less ","code_information":[{"code":"12001","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CEBPA (CCAAT/enhancer binding protein ºC/EBP», alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence ","code_information":[{"code":"81218","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":217.710,"maximum":421.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":217.710,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":244.320,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":217.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":217.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":217.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":217.710,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":254.000,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":249.160,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":246.740,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":254.000,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":421.080,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":246.740,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":362.850,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":254.000,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":254.000,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":234.640,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":290.280,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":244.320,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":244.320,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":244.320,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":362.850,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":254.000,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":246.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":246.740,"methodology":"fee schedule"}]}]},{"description":"Re-exploration of pelvic wound with removal of preperitoneal pelvic packing, including repacking, when performed ","code_information":[{"code":"490","type":"RC"},{"code":"49014","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm ","code_information":[{"code":"12054","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"CERVICAL SPINAL FUSION WITHOUT CC/MCC ","code_information":[{"code":"122","type":"RC"},{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18969.520,"maximum":18969.520,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18969.520,"methodology":"fee schedule"}]}]},{"description":"MLH1 (mutL homolog 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (List separately in addition to code for primary procedure) ","code_information":[{"code":"0158U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":282.880,"maximum":333.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":333.800,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; with contrast material ","code_information":[{"code":"341","type":"RC"},{"code":"72129","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS ","code_information":[{"code":"2811","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4576.900,"maximum":6865.350,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":4576.900,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":4668.440,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":6865.350,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":4576.900,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":4576.900,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":4576.900,"methodology":"fee schedule"}]}]},{"description":"Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); ","code_information":[{"code":"60540","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22843","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":39140.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":16000.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":39140.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) ","code_information":[{"code":"25446","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":25632.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy ","code_information":[{"code":"43865","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) ","code_information":[{"code":"29882","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); corneovitreal adhesions ","code_information":[{"code":"369","type":"RC"},{"code":"65880","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1488.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Injection, methocarbamol, up to 10 ml ","drug_information":{"unit":1.000000000000000e+001,"type":"ML"},"code_information":[{"code":"636","type":"RC"},{"code":"913421","type":"CDM"},{"code":"J2800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":9.760,"maximum":9.760,"gross_charge":333.50,"discounted_cash":333.50,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.760,"methodology":"fee schedule"}]}]},{"description":"Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use ","code_information":[{"code":"344","type":"RC"},{"code":"90644","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":50.980,"maximum":50.980,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":50.980,"methodology":"fee schedule"}]}]},{"description":"Hemolysin, acid ","code_information":[{"code":"85475","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.290,"maximum":10.470,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.870,"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":"312","type":"RC"},{"code":"87340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.330,"maximum":12.190,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.190,"methodology":"fee schedule"}]}]},{"description":"Repair of coronary arteriovenous or arteriocardiac chamber fistula; without cardiopulmonary bypass ","code_information":[{"code":"33501","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Suprachoroidal space injection of pharmacologic agent (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"67516","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33381.030,"maximum":33381.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33381.030,"methodology":"fee schedule"}]}]},{"description":"Angiography, pelvic, selective or supraselective, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75736","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":67.490,"maximum":82.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":67.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":76.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":67.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":82.080,"methodology":"fee schedule"}]}]},{"description":"MOUTH PROCEDURES WITH CC/MCC ","code_information":[{"code":"137","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5665.460,"maximum":6132.720,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":6132.720,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":5665.460,"methodology":"fee schedule"}]}]},{"description":"Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu ","code_information":[{"code":"J7182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.360,"maximum":3.750,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":1.660,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":1.830,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":2.690,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":3.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":1.360,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":3.750,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":1.790,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":3.600,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":3.670,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":3.750,"methodology":"fee schedule"}]}]},{"description":"Cineradiography/videoradiography, except where specifically included ","code_information":[{"code":"320","type":"RC"},{"code":"76120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":245.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":160.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":181.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":160.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":194.580,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":143.850,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":128.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"MINOR BLADDER PROCEDURES WITH CC ","code_information":[{"code":"121","type":"RC"},{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12403.210,"maximum":12403.210,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12403.210,"methodology":"fee schedule"}]}]},{"description":"Removal of transvenous pacemaker electrode(s); dual lead system ","code_information":[{"code":"33235","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; ","code_information":[{"code":"15936","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous ","code_information":[{"code":"481","type":"RC"},{"code":"49406","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22139.680,"maximum":22139.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22139.680,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) ","code_information":[{"code":"351","type":"RC"},{"code":"70481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":401.740,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Antibody; histoplasma ","code_information":[{"code":"303","type":"RC"},{"code":"86698","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.890,"maximum":16.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.170,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.790,"methodology":"fee schedule"}]}]},{"description":"Hemolysins and agglutinins; incubated ","code_information":[{"code":"303","type":"RC"},{"code":"86941","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.320,"maximum":14.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.110,"methodology":"fee schedule"}]}]},{"description":"Oxalate ","code_information":[{"code":"300","type":"RC"},{"code":"83945","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.510,"maximum":17.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.900,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.450,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.450,"methodology":"fee schedule"}]}]},{"description":"Angiography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75710","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":97.360,"maximum":118.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":97.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":110.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":97.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":118.400,"methodology":"fee schedule"}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC ","code_information":[{"code":"075","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15235.480,"maximum":15235.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15235.480,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13514.580,"maximum":13514.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13514.580,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC ","code_information":[{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":47913.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":43617.350,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":16522.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":43617.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":43617.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":43617.350,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":31155.250,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":39390.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":44683.540,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":16849.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":39390.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47913.600,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":20448.460,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":16685.950,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":13904.950,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":13904.950,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":16685.950,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":16685.950,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":24471.100,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":17013.120,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":23728.640,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17013.120,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":15868.010,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":17796.480,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16522.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":16522.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":16522.360,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":16358.770,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":16358.770,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":16358.770,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":24970.510,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":26157.160,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":21558.490,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":25908.720,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":19844.760,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":17013.120,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":23971.690,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":17013.120,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":24471.100,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":24538.150,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17176.710,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":16358.770,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":24970.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16015.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":16358.770,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":16358.770,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":16685.950,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC ","code_information":[{"code":"057","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":10802.090,"maximum":10802.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10802.090,"methodology":"fee schedule"}]}]},{"description":"Growth hormone suppression panel (glucose administration) This panel must include the following: Glucose (82947 x 3) Human growth hormone (HGH) (83003 x 4) ","code_information":[{"code":"305","type":"RC"},{"code":"80430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":120.920,"maximum":152.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":120.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":142.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":120.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":142.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":129.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":152.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":129.330,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; subclavian-subclavian ","code_information":[{"code":"35511","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"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":128.280,"maximum":156.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":145.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":156.000,"methodology":"fee schedule"}]}]},{"description":"Esophagoplasty (plastic repair or reconstruction), cervical approach; without repair of tracheoesophageal fistula ","code_information":[{"code":"43300","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) ","code_information":[{"code":"369","type":"RC"},{"code":"47141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, mandible; partial, less than 4 views ","code_information":[{"code":"324","type":"RC"},{"code":"70100","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":44.410,"maximum":54.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":44.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":44.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":54.010,"methodology":"fee schedule"}]}]},{"description":"Repair of anomalous coronary artery from pulmonary artery origin; by ligation ","code_information":[{"code":"33502","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC ","code_information":[{"code":"210","type":"RC"},{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":45203.390,"maximum":45203.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":45203.390,"methodology":"fee schedule"}]}]},{"description":"Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified ","code_information":[{"code":"891","type":"RC"},{"code":"J7192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.420,"maximum":3.420,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.420,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible; with directed submucosal injection(s), any substance ","code_information":[{"code":"45381","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16299.090,"maximum":16299.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16299.090,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0350U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1249.240,"maximum":1576.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1249.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1469.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1249.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1469.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1336.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1576.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1336.090,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC ","code_information":[{"code":"144","type":"RC"},{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7859.330,"maximum":7859.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7859.330,"methodology":"fee schedule"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; simple ","code_information":[{"code":"324","type":"RC"},{"code":"77280","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":50.640,"maximum":61.580,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":57.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":61.580,"methodology":"fee schedule"}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition ","code_information":[{"code":"19286","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); INCARCERATED OR STRANGULATED ","code_information":[{"code":"49657","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Donor cardiectomy (including cold preservation) ","code_information":[{"code":"33940","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Antibody; Diphtheria ","code_information":[{"code":"319","type":"RC"},{"code":"86648","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.210,"maximum":17.950,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.950,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT C ","code_information":[{"code":"212","type":"RC"},{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6554.060,"maximum":6554.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6554.060,"methodology":"fee schedule"}]}]},{"description":"REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITHOUT VAGOTOMY ","code_information":[{"code":"361","type":"RC"},{"code":"43850","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7411.200,"maximum":7411.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes ","code_information":[{"code":"360","type":"RC"},{"code":"51585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncology, whole blood or buccal,DNA single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, with variant analysis and reported phenotypes ","code_information":[{"code":"0460U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":917.080,"maximum":1082.150,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":917.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1082.150,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17124.600,"maximum":17124.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17124.600,"methodology":"fee schedule"}]}]},{"description":"Stump elongation, upper extremity ","code_information":[{"code":"24935","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection ","code_information":[{"code":"41145","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common variants (eg, E285A, Y231X) ","code_information":[{"code":"306","type":"RC"},{"code":"81200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.180,"maximum":55.750,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":44.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":51.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":44.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":51.980,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":47.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":55.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":47.250,"methodology":"fee schedule"}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15330.990,"maximum":15330.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15330.990,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH CC ","code_information":[{"code":"214","type":"RC"},{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14891.150,"maximum":14891.150,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14891.150,"methodology":"fee schedule"}]}]},{"description":"Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute ","code_information":[{"code":"23410","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INBORN ERRORS OF METABOLISM ","code_information":[{"code":"4233","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6166.100,"maximum":9249.150,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":6166.100,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":6289.420,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":9249.150,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":6166.100,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":6166.100,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":6166.100,"methodology":"fee schedule"}]}]},{"description":"Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; pulse generator only ","code_information":[{"code":"64656","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateral ","code_information":[{"code":"342","type":"RC"},{"code":"76513","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Estrogens; fractionated ","code_information":[{"code":"314","type":"RC"},{"code":"82671","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.300,"maximum":38.110,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":32.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":38.110,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"213","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22139.680,"maximum":22139.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22139.680,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Trichomonas vaginalis ","code_information":[{"code":"305","type":"RC"},{"code":"87808","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.300,"maximum":18.040,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.290,"methodology":"fee schedule"}]}]},{"description":"Urinary bladder residual study (List separately in addition to code for primary procedure) ","code_information":[{"code":"341","type":"RC"},{"code":"78730","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":10.550,"maximum":12.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.160,"methodology":"fee schedule"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion ","code_information":[{"code":"38210","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; ","code_information":[{"code":"362","type":"RC"},{"code":"52005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of a ","code_information":[{"code":"33957","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin ","code_information":[{"code":"303","type":"RC"},{"code":"88740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.760,"maximum":11.060,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.370,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ankle; complete, minimum of 3 views ","code_information":[{"code":"322","type":"RC"},{"code":"73610","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":40.630,"maximum":49.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":40.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":46.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":40.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.410,"methodology":"fee schedule"}]}]},{"description":"Injection, luspatercept-aamt, 0.25 mg ","code_information":[{"code":"J0896","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":40.000,"maximum":108.130,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":46.960,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":47.890,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":70.430,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":105.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":40.000,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":108.130,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":46.950,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":103.800,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":105.970,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":108.130,"methodology":"fee schedule"}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC ","code_information":[{"code":"122","type":"RC"},{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16662.640,"maximum":16662.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16662.640,"methodology":"fee schedule"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; for removal of lesion ","code_information":[{"code":"66600","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reduction of procidentia (separate procedure) under anesthesia ","code_information":[{"code":"45900","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg ","code_information":[{"code":"344","type":"RC"},{"code":"Q5107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":51.260,"maximum":51.260,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":51.260,"methodology":"fee schedule"}]}]},{"description":"Sanograft, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with removal of pulmonary band ","code_information":[{"code":"33775","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Culture, presumptive, pathogenic organisms, screening only; ","code_information":[{"code":"87081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.670,"maximum":11.530,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":6.700,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":6.960,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":6.830,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":6.760,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":6.960,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11.530,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":6.760,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":9.950,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":6.960,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":6.960,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":6.430,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":7.960,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":6.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":6.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":6.700,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":9.950,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":6.960,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":6.630,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":6.760,"methodology":"fee schedule"}]}]},{"description":"Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation ","code_information":[{"code":"610","type":"RC"},{"code":"76519","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Open treatment of orbital floor blowout fracture; periorbital approach ","code_information":[{"code":"21386","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of wrist prosthesis; (separate procedure) ","code_information":[{"code":"25250","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algo ","code_information":[{"code":"0003M","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":503.400,"maximum":594.010,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":503.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":594.010,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33381.030,"maximum":33381.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33381.030,"methodology":"fee schedule"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23189.040,"maximum":23189.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23189.040,"methodology":"fee schedule"}]}]},{"description":"Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, Nikaidoh procedure); with reimplantation of 1 or both coronary ostia ","code_information":[{"code":"33783","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0DV67ZZ","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) ","code_information":[{"code":"15769","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14037.130,"maximum":14037.130,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14037.130,"methodology":"fee schedule"}]}]},{"description":"CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant ","code_information":[{"code":"302","type":"RC"},{"code":"81186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":173.160,"maximum":218.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":218.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm ","code_information":[{"code":"14001","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands ","code_information":[{"code":"369","type":"RC"},{"code":"42509","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Cholecystectomy; with cholangiography ","code_information":[{"code":"47605","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of radial shaft fracture; without manipulation ","code_information":[{"code":"25500","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6948.280,"maximum":6948.280,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6948.280,"methodology":"fee schedule"}]}]},{"description":"Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical ","code_information":[{"code":"362","type":"RC"},{"code":"61860","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm ","code_information":[{"code":"21555","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) ","code_information":[{"code":"340","type":"RC"},{"code":"74182","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, a ","code_information":[{"code":"790","type":"RC"},{"code":"C9608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":26780.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13647.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15481.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13647.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16600.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":16014.100,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26780.000,"methodology":"case rate"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC ","code_information":[{"code":"219","type":"RC"},{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":45203.390,"maximum":45203.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":45203.390,"methodology":"fee schedule"}]}]},{"description":"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11157.820,"maximum":11157.820,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11157.820,"methodology":"fee schedule"}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13884.570,"maximum":13884.570,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13884.570,"methodology":"fee schedule"}]}]},{"description":"Capsulorrhaphy, anterior, any type; with coracoid process transfer ","code_information":[{"code":"23462","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"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":"311","type":"RC"},{"code":"87339","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.000,"maximum":18.880,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.880,"methodology":"fee schedule"}]}]},{"description":"Drainage of finger abscess; simple ","code_information":[{"code":"26010","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis appendage) (separate procedure) ","code_information":[{"code":"65125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":6009.740,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":5889.550,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":6009.740,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":5769.350,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":5889.550,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":6009.740,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":34250.030,"maximum":34250.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":34250.030,"methodology":"fee schedule"}]}]},{"description":"Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diamet ","code_information":[{"code":"0080U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3291.200,"maximum":4153.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3291.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3872.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3291.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3872.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4153.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3520.000,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20462.290,"maximum":20462.290,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20462.290,"methodology":"fee schedule"}]}]},{"description":"Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation ","code_information":[{"code":"306","type":"RC"},{"code":"83625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.960,"maximum":15.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.070,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.790,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.790,"methodology":"fee schedule"}]}]},{"description":"Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) ","code_information":[{"code":"20939","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus) ","code_information":[{"code":"305","type":"RC"},{"code":"87631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":133.360,"maximum":168.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":133.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":156.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":133.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":156.890,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":168.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":142.630,"methodology":"fee schedule"}]}]},{"description":"Injection, gamma globulin, intramuscular, over 10 cc ","code_information":[{"code":"891","type":"RC"},{"code":"J1560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":224.720,"maximum":224.720,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":224.720,"methodology":"fee schedule"}]}]},{"description":"Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction ","code_information":[{"code":"362","type":"RC"},{"code":"69636","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) ","code_information":[{"code":"31237","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical therapy, unlisted procedure ","code_information":[{"code":"618","type":"RC"},{"code":"79999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":264.470,"maximum":264.470,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":264.470,"methodology":"fee schedule"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multi ","code_information":[{"code":"15017","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft) ","code_information":[{"code":"28420","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, teeth; partial examination, less than full mouth ","code_information":[{"code":"351","type":"RC"},{"code":"70310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter) ","code_information":[{"code":"499","type":"RC"},{"code":"62161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Application, cast; figure-of-eight ","code_information":[{"code":"29049","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; ","code_information":[{"code":"490","type":"RC"},{"code":"67036","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Exchange of intraocular lens ","code_information":[{"code":"66986","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method ","code_information":[{"code":"28297","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Open treatment of mandibular fracture with external fixation ","code_information":[{"code":"21454","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; other vein ","code_information":[{"code":"36406","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALLERGIC REACTIONS WITHOUT MCC ","code_information":[{"code":"156","type":"RC"},{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6315.960,"maximum":6315.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6315.960,"methodology":"fee schedule"}]}]},{"description":"Ureteroneocystostomy; anastomosis of single ureter to bladder ","code_information":[{"code":"360","type":"RC"},{"code":"50780","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneo ","code_information":[{"code":"361","type":"RC"},{"code":"61619","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Growth hormone suppression panel (glucose administration) This panel must include the following: Glucose (82947 x 3) Human growth hormone (HGH) (83003 x 4) ","code_information":[{"code":"306","type":"RC"},{"code":"80430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":120.920,"maximum":152.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":120.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":142.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":120.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":142.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":129.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":152.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":129.330,"methodology":"fee schedule"}]}]},{"description":"Cholecystectomy; with cholangiography ","code_information":[{"code":"47605","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Osteotomy, humerus, with or without internal fixation ","code_information":[{"code":"24400","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair, laceration of palate; over 2 cm or complex ","code_information":[{"code":"367","type":"RC"},{"code":"42182","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"67025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty ","code_information":[{"code":"24587","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"204","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8873.040,"maximum":8873.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8873.040,"methodology":"fee schedule"}]}]},{"description":"Suture of posterior tibial nerve ","code_information":[{"code":"480","type":"RC"},{"code":"64840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each ","code_information":[{"code":"28510","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance ","code_information":[{"code":"19285","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"RED BLOOD CELL DISORDERS WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11576.990,"maximum":11576.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11576.990,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, m ","code_information":[{"code":"0321U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":593.580,"maximum":749.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":593.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":698.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":593.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":698.320,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":749.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":634.840,"methodology":"fee schedule"}]}]},{"description":"Exploration of orbit (transcranial approach), with removal of lesion ","code_information":[{"code":"369","type":"RC"},{"code":"61333","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"55200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES ","code_information":[{"code":"151","type":"RC"},{"code":"212","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":79084.990,"maximum":79084.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":79084.990,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of shoulder area; deep ","code_information":[{"code":"23066","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Blood count; reticulocyte, manual ","code_information":[{"code":"85044","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4.030,"maximum":5.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.310,"methodology":"fee schedule"}]}]},{"description":"Mastectomy for gynecomastia ","code_information":[{"code":"19300","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Removal of intrauterine device (IUD) ","code_information":[{"code":"58301","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"151","type":"RC"},{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":34913.010,"maximum":34913.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":34913.010,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) ","code_information":[{"code":"352","type":"RC"},{"code":"70336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention ","code_information":[{"code":"341","type":"RC"},{"code":"78707","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":234.990,"maximum":270.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":234.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":266.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":234.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":270.900,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; metatarsal ","code_information":[{"code":"28173","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tensix, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12086.690,"maximum":12086.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12086.690,"methodology":"fee schedule"}]}]},{"description":"Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) ","code_information":[{"code":"22527","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure) ","code_information":[{"code":"321","type":"RC"},{"code":"78020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":87.310,"maximum":113.180,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":113.180,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":87.310,"methodology":"fee schedule"}]}]},{"description":"Inj, vivimusta, 1 mg ","code_information":[{"code":"9154","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":31.030,"maximum":47.990,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":32.310,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":32.950,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":33.590,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":32.630,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":31.990,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":33.590,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":33.590,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":31.030,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":32.310,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":32.310,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":32.310,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":31.990,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":31.990,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":31.990,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":47.990,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":33.590,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":31.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":32.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":31.990,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":32.630,"methodology":"fee schedule"}]}]},{"description":"PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION ","code_information":[{"code":"402","type":"RC"},{"code":"74710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.830,"maximum":36.830,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":36.830,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0DV60CZ","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8001.200,"maximum":8001.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8001.200,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique ","code_information":[{"code":"310","type":"RC"},{"code":"87550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.050,"maximum":23.660,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.660,"methodology":"fee schedule"}]}]},{"description":"Exploration not followed by surgical repair, artery; upper extremity (eg, axillary, brachial, radial, ulnar) ","code_information":[{"code":"35702","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fibrin degradation products, D-dimer; quantitative ","code_information":[{"code":"309","type":"RC"},{"code":"85379","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.520,"maximum":12.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.180,"methodology":"fee schedule"}]}]},{"description":"Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure ","code_information":[{"code":"11006","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"219","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5293.690,"maximum":5293.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5293.690,"methodology":"fee schedule"}]}]},{"description":"Cadmium ","code_information":[{"code":"82300","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22.100,"maximum":27.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":22.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":26.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":22.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":23.640,"methodology":"fee schedule"}]}]},{"description":"Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at res ","code_information":[{"code":"93924","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":393.460,"maximum":409.850,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":401.650,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":409.850,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":393.460,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":401.650,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":409.850,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"023","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":42416.040,"maximum":42416.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":42416.040,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":11463.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":10399.650,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":5044.540,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":10399.650,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":10399.650,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":10399.650,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":7428.320,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9391.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10653.860,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":5144.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9391.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11424.000,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":6243.240,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":5094.490,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":4245.400,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":4245.400,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":5094.490,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":5094.490,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":5282.070,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":5194.380,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5657.600,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":5194.380,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":4844.760,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4243.200,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5044.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":5044.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":5044.540,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":4994.590,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":4994.590,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":4994.590,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":5389.870,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":5646.010,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":4653.390,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":5592.380,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":4283.480,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":5194.380,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10744.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":5174.280,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":5194.380,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":5282.070,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":7491.890,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5244.320,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":4994.590,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":5389.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10391.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4889.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":4994.590,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":4994.590,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":5094.490,"methodology":"fee schedule"}]}]},{"description":"Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy ","code_information":[{"code":"360","type":"RC"},{"code":"58954","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Release, intrinsic muscles of hand, each muscle ","code_information":[{"code":"26593","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells ","code_information":[{"code":"88245","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":204.340,"maximum":204.340,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":204.340,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 24 ","code_information":[{"code":"01561","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2865.240,"maximum":2865.240,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2865.240,"methodology":"fee schedule"}]}]},{"description":"Injection, vancomycin hydrochloride (mylan) not therapeutically equivalent to j3373, 10 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J3374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.220,"maximum":0.220,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.220,"methodology":"fee schedule"}]}]},{"description":"Insertion of pacemaker pulse generator only; with existing single lead ","code_information":[{"code":"33212","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":23762.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":10298.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":6955.740,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":23762.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5989.000,"methodology":"case rate"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7097.690,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":3850.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":6813.780,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":3850.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":6955.740,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7097.690,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Inj recombin esperoct per ","code_information":[{"code":"9354","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.170,"maximum":3.360,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":2.260,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":2.310,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":2.350,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":2.280,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":2.350,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":2.350,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":2.170,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":2.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":2.260,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":3.360,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":2.350,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":2.280,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"616","type":"RC"},{"code":"71275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Inj., plazomicin, 5 mg ","code_information":[{"code":"09183","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3.400,"maximum":3.400,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":3.400,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty wi ","code_information":[{"code":"C9765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21408.520,"maximum":22300.540,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":21854.530,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":22300.540,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":21408.520,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":21854.530,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":22300.540,"methodology":"fee schedule"}]}]},{"description":"Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepa ","code_information":[{"code":"360","type":"RC"},{"code":"47143","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of Meckel's diverticulum (diverticulectomy) or omphalomesenteric duct ","code_information":[{"code":"44800","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Thyroglobulin ","code_information":[{"code":"303","type":"RC"},{"code":"84432","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.020,"maximum":18.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.670,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.060,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.060,"methodology":"fee schedule"}]}]},{"description":"Doppler velocimetry, fetal; middle cerebral artery ","code_information":[{"code":"323","type":"RC"},{"code":"76821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":98.850,"maximum":125.480,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":111.120,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":98.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Repair choanal atresia; transpalatine ","code_information":[{"code":"30545","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Rare diseases, whole genome sequence analysis, incl small sequence changes, copy number variants, deletions, duplications, mobile element insertions, UPD, inversions, aneuploidy, mitochondrial genome ","code_information":[{"code":"0335U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5224.600,"maximum":6165.030,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5224.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6165.030,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body in scrotum ","code_information":[{"code":"481","type":"RC"},{"code":"55120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"SPLENIC PROCEDURES WITH MCC ","code_information":[{"code":"150","type":"RC"},{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33851.530,"maximum":33851.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33851.530,"methodology":"fee schedule"}]}]},{"description":"SICKLE CELL ANEMIA CRISIS ","code_information":[{"code":"6621","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5276.140,"maximum":7914.210,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":5276.140,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5381.660,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":7914.210,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":5276.140,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":5276.140,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":5276.140,"methodology":"fee schedule"}]}]},{"description":"Oncology (cutaneous melanoma), RNA, gene expression profiling by realtime qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed ","code_information":[{"code":"0578U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3621.260,"maximum":4570.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3621.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4260.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3621.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4260.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3873.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4570.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3873.000,"methodology":"fee schedule"}]}]},{"description":"Open treatment of radial shaft fracture, includes internal fixation, when performed ","code_information":[{"code":"25515","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial ","code_information":[{"code":"21248","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Computed tomography, upper extremity; with contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"73201","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":206.810,"maximum":251.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":206.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":234.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":206.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":251.510,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with endoscopic mucosal resection ","code_information":[{"code":"43211","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); without pancreatojejunostomy ","code_information":[{"code":"48152","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, facial bones; less than 3 views ","code_information":[{"code":"400","type":"RC"},{"code":"70140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.320,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":44.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":44.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":53.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual ","code_information":[{"code":"41015","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":33460.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":28570.360,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":11323.120,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":28570.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":28570.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":28570.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":20407.400,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25801.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29268.740,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":11547.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25801.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31384.500,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":14013.760,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":31092.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":23320.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":31092.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31092.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":11435.230,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":9529.360,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":9529.360,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":11435.230,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":11435.230,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":15083.640,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":11659.450,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15542.800,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":11659.450,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":10874.680,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":11657.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11323.120,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":11323.120,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":11323.120,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":11211.010,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":11211.010,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":11211.010,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":15391.470,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":16122.910,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":13288.350,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":15969.770,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":12232.030,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":11659.450,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":14775.810,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":11659.450,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":15083.640,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":16816.510,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11771.560,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":11211.010,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":15391.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33460.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10975.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":11211.010,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":11211.010,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":11435.230,"methodology":"fee schedule"}]}]},{"description":"Decompressive fasciotomy, hand (excludes 26035) ","code_information":[{"code":"26037","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, elranatamab-bcmm, 1 mg ","code_information":[{"code":"J1323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":177.490,"maximum":465.350,"payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":211.470,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":310.980,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":456.040,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":177.490,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":465.350,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":207.320,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":446.740,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":456.040,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":465.350,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL74ZZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3296.000,"maximum":3296.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3296.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Angiography, pelvic, selective or supraselective, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75736","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":159.610,"maximum":10733.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":199.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":226.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":199.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":242.400,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":201.790,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":159.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6378.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10733.330,"methodology":"fee schedule"}]}]},{"description":"Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of ","code_information":[{"code":"81442","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2004.270,"maximum":2529.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2004.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2357.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2004.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2357.960,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2529.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2143.600,"methodology":"fee schedule"}]}]},{"description":"Injection, brolucizumab-dbll, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":758.540,"maximum":758.540,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":758.540,"methodology":"fee schedule"}]}]},{"description":"Glutathione ","code_information":[{"code":"306","type":"RC"},{"code":"82978","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.450,"maximum":18.230,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.450,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.450,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12137.300,"maximum":12137.300,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12137.300,"methodology":"fee schedule"}]}]},{"description":"Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) ","code_information":[{"code":"29851","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":11616.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC ","code_information":[{"code":"070","type":"MS-DRG"},{"code":"173","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":13434.030,"maximum":13434.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13434.030,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"124","type":"RC"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"AFTERCARE WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6040.790,"maximum":6040.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6040.790,"methodology":"fee schedule"}]}]},{"description":"Vestibular nerve section, translabyrinthine approach ","code_information":[{"code":"369","type":"RC"},{"code":"69915","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"111","type":"RC"},{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11185.610,"maximum":11185.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11185.610,"methodology":"fee schedule"}]}]},{"description":"Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"93613","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":37080.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7705.530,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8741.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7705.530,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9372.930,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":9041.920,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":37080.000,"methodology":"case rate"}]}]},{"description":"Repair of hypospadias complication(s) (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple ","code_information":[{"code":"360","type":"RC"},{"code":"54340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC ","code_information":[{"code":"219","type":"RC"},{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24262.630,"maximum":24262.630,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24262.630,"methodology":"fee schedule"}]}]},{"description":"Level 2 Radiation Therapy ","code_information":[{"code":"05622","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":347.350,"maximum":347.350,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":347.350,"methodology":"fee schedule"}]}]},{"description":"Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring) ","code_information":[{"code":"369","type":"RC"},{"code":"53500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with endoscopic ","code_information":[{"code":"66988","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":9764.400,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":9569.110,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":9764.400,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":9373.820,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":9569.110,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":9764.400,"methodology":"fee schedule"}]}]},{"description":"Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel ","code_information":[{"code":"321","type":"RC"},{"code":"77767","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":272.060,"maximum":428.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":352.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":399.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":352.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":428.510,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":272.060,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.320,"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"58552","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":24184.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":18137.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Pyruvate kinase ","code_information":[{"code":"303","type":"RC"},{"code":"84220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.830,"maximum":11.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10.380,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.440,"methodology":"fee schedule"}]}]},{"description":"Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 ","code_information":[{"code":"480","type":"RC"},{"code":"C5277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5988.600,"maximum":7284.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Closed treatment of femoral fracture, proximal end, neck; without manipulation ","code_information":[{"code":"27230","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"322","type":"RC"},{"code":"74240","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":51.240,"maximum":62.310,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":51.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":58.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":51.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":62.310,"methodology":"fee schedule"}]}]},{"description":"FULL TERM NEONATE WITH MAJOR PROBLEMS ","code_information":[{"code":"126","type":"RC"},{"code":"793","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":31290.170,"maximum":31290.170,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":31290.170,"methodology":"fee schedule"}]}]},{"description":"Anorectal myomectomy ","code_information":[{"code":"45108","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5.1-10.0 cm diameter ","code_information":[{"code":"490","type":"RC"},{"code":"49204","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":10520.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Maxillectomy; without orbital exenteration ","code_information":[{"code":"31225","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body ","code_information":[{"code":"23107","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, renin), radiological supervision and interpretation ","code_information":[{"code":"349","type":"RC"},{"code":"75893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6378.730,"maximum":6378.730,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6378.730,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) ","code_information":[{"code":"29874","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Neuroplasty, major peripheral nerve, arm or leg, open; other than specified ","code_information":[{"code":"64708","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted fluoroscopic procedure (eg, diagnostic, interventional) ","code_information":[{"code":"349","type":"RC"},{"code":"76496","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12140.880,"maximum":12140.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12140.880,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor, radial head or neck ","code_information":[{"code":"24152","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"401","type":"RC"},{"code":"72191","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe ","code_information":[{"code":"31660","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM ","code_information":[{"code":"141","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11703.880,"maximum":11703.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11703.880,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) ","code_information":[{"code":"614","type":"RC"},{"code":"76857","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) ","code_information":[{"code":"615","type":"RC"},{"code":"78811","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.470,"maximum":1540.470,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1540.470,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9527.470,"maximum":9527.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9527.470,"methodology":"fee schedule"}]}]},{"description":"Digoxin; free ","code_information":[{"code":"307","type":"RC"},{"code":"80163","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.420,"maximum":15.670,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.610,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.280,"methodology":"fee schedule"}]}]},{"description":"Alcohol (ethanol); breath ","code_information":[{"code":"314","type":"RC"},{"code":"82075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.000,"maximum":35.400,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":35.400,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"212","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8512.330,"maximum":8512.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8512.330,"methodology":"fee schedule"}]}]},{"description":"Stem cells (ie, CD34), total count ","code_information":[{"code":"311","type":"RC"},{"code":"86367","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":77.780,"maximum":91.780,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":77.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":91.780,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage ","code_information":[{"code":"31624","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Proctopexy (eg, for prolapse); perineal approach ","code_information":[{"code":"360","type":"RC"},{"code":"45541","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Leuprolide acetate ","code_information":[{"code":"00800","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1710.950,"maximum":1710.950,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":1710.950,"methodology":"fee schedule"}]}]},{"description":"Urobilinogen, urine; quantitative, timed specimen ","code_information":[{"code":"301","type":"RC"},{"code":"84580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.930,"maximum":11.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10.510,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.550,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.550,"methodology":"fee schedule"}]}]},{"description":"Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score ","code_information":[{"code":"0069U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":355.300,"maximum":448.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":355.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":418.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":355.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":418.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":380.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":448.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":380.000,"methodology":"fee schedule"}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space ","code_information":[{"code":"41018","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"114","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9712.100,"maximum":9712.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9712.100,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOT ","code_information":[{"code":"146","type":"RC"},{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35814.790,"maximum":35814.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":35814.790,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, pelvis; complete, minimum of 3 views ","code_information":[{"code":"618","type":"RC"},{"code":"72190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection ","code_information":[{"code":"319","type":"RC"},{"code":"87250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.560,"maximum":23.080,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.080,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0DP643Z","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ABORTION WITHOUT D&C ","code_information":[{"code":"174","type":"RC"},{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7563.490,"maximum":7563.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7563.490,"methodology":"fee schedule"}]}]},{"description":"Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) ","code_information":[{"code":"13153","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views ","code_information":[{"code":"350","type":"RC"},{"code":"71101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH CC ","code_information":[{"code":"038","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":13133.190,"maximum":13133.190,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13133.190,"methodology":"fee schedule"}]}]},{"description":"Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count ","code_information":[{"code":"310","type":"RC"},{"code":"89051","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.600,"maximum":6.610,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.610,"methodology":"fee schedule"}]}]},{"description":"Craniectomy or craniotomy; with excision of foreign body from brain ","code_information":[{"code":"369","type":"RC"},{"code":"61570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) ","code_information":[{"code":"20930","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, knee; 3 views ","code_information":[{"code":"409","type":"RC"},{"code":"73562","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":59.510,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":59.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":67.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":59.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":72.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative ","code_information":[{"code":"81207","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":110.090,"maximum":252.120,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":146.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":115.590,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":149.190,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":112.290,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":152.080,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":252.120,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":147.740,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":165.130,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":144.840,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":152.080,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":152.080,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":140.490,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":173.810,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":146.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":146.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":146.290,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":144.840,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":144.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":144.840,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":110.090,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":217.260,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":152.080,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":144.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":147.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":144.840,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":147.740,"methodology":"fee schedule"}]}]},{"description":"Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs ","code_information":[{"code":"21813","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"DEPRESSIVE NEUROSES ","code_information":[{"code":"201","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8273.520,"maximum":8273.520,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8273.520,"methodology":"fee schedule"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23095.650,"maximum":23095.650,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23095.650,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; intermediate ","code_information":[{"code":"350","type":"RC"},{"code":"77762","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.600,"maximum":682.600,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"Endoscopic submucosal dissection (esd), including endoscopy or colonoscopy, mucosal closure, when performed ","code_information":[{"code":"490","type":"RC"},{"code":"C9779","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":7417.150,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, proximal or middle phalanx of finger ","code_information":[{"code":"26260","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":31171.830,"maximum":31171.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":31171.830,"methodology":"fee schedule"}]}]},{"description":"Cryoprecipitate each unit ","code_information":[{"code":"09511","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":69.790,"maximum":69.790,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":69.790,"methodology":"fee schedule"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"209","type":"RC"},{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9891.030,"maximum":9891.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9891.030,"methodology":"fee schedule"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC ","code_information":[{"code":"212","type":"RC"},{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18990.200,"maximum":18990.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18990.200,"methodology":"fee schedule"}]}]},{"description":"Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) ","code_information":[{"code":"21151","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"75743","type":"CPT"},{"code":"806233","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":146.060,"maximum":146.060,"gross_charge":21840.00,"discounted_cash":21840.00,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":146.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":146.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":146.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":146.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":146.060,"methodology":"fee schedule"}]}]},{"description":"REVISION OR REPLACEMENT OF CHEST WALL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY, INCLUDING CONNECTION TO EXISTING PULSE GENERATOR ","code_information":[{"code":"0467T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7411.200,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"127","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27412.840,"maximum":27412.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27412.840,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments ","code_information":[{"code":"22812","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated ","code_information":[{"code":"40801","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH CC ","code_information":[{"code":"210","type":"RC"},{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10189.020,"maximum":10189.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10189.020,"methodology":"fee schedule"}]}]},{"description":"Transfer, free toe joint, with microvascular anastomosis ","code_information":[{"code":"26556","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique ","code_information":[{"code":"309","type":"RC"},{"code":"87661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.810,"maximum":41.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"75891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when perfor ","code_information":[{"code":"52284","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation or banding of angioaccess arteriovenous fistula ","code_information":[{"code":"37607","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncology (breast ductal carcinoma in situ), mRNA, gene expression progiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm ","code_information":[{"code":"0045U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3621.260,"maximum":4570.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3621.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4260.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3621.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4260.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3873.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4570.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3873.000,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of proximal fibula or shaft fracture; without manipulation ","code_information":[{"code":"27780","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"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":"306","type":"RC"},{"code":"87301","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.200,"maximum":14.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.980,"methodology":"fee schedule"}]}]},{"description":"Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) ","code_information":[{"code":"27177","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EXPIRED, NOT ORTHOPEDIC, LENGTH OF STAY IS 16 DAYS ","code_information":[{"code":"024","type":"RC"},{"code":"A5104","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":35265.630,"maximum":35265.630,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":35265.630,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC ","code_information":[{"code":"219","type":"RC"},{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35012.820,"maximum":35012.820,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":35012.820,"methodology":"fee schedule"}]}]},{"description":"Theophylline ","code_information":[{"code":"304","type":"RC"},{"code":"80198","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.220,"maximum":16.690,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.550,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.140,"methodology":"fee schedule"}]}]},{"description":"Repair, flexor tendon, leg; secondary, with or without graft, each tendon ","code_information":[{"code":"27659","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Sympathectomy; radial artery ","code_information":[{"code":"64821","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC ","code_information":[{"code":"143","type":"RC"},{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8697.680,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8697.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Insertion or replacement of epicranial neurostimulator system, including electrode array and pulse generator, with connection to electrode array ","code_information":[{"code":"0968T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Oncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a ","code_information":[{"code":"0003U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":950.000,"maximum":1121.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":950.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1121.000,"methodology":"fee schedule"}]}]},{"description":"MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medica ","code_information":[{"code":"324","type":"RC"},{"code":"76019","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":37.680,"maximum":45.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.820,"methodology":"fee schedule"}]}]},{"description":"Excision of rectal procidentia, with anastomosis; abdominal and perineal approach ","code_information":[{"code":"45135","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision mastoidectomy; resulting in radical mastoidectomy ","code_information":[{"code":"69603","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tracheobronchoscopy through established tracheostomy incision ","code_information":[{"code":"31615","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Excision of cervical stump, abdominal approach; ","code_information":[{"code":"481","type":"RC"},{"code":"57540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radiopharmaceutical therapy, by interstitial radioactive colloid administration ","code_information":[{"code":"320","type":"RC"},{"code":"79300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":75.200,"maximum":264.470,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":75.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":264.470,"methodology":"fee schedule"}]}]},{"description":"Creatine kinase (CK), (CPK); isoforms ","code_information":[{"code":"302","type":"RC"},{"code":"82554","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.100,"maximum":14.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.870,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.870,"methodology":"fee schedule"}]}]},{"description":"Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and ","code_information":[{"code":"15121","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncology (ovarian), biochemical assays of 7 proteins (follicle stimulating hormone, human epididymis protein 4, apolipoprotein A-1, transferrin, beta-2 macroglobulin, prea0lbumin, and cancer antigen 1 ","code_information":[{"code":"0375U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":897.000,"maximum":1058.460,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1058.460,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10923.990,"maximum":10923.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10923.990,"methodology":"fee schedule"}]}]},{"description":"UNGROUPABLE ","code_information":[{"code":"101","type":"RC"},{"code":"999","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1566.060,"maximum":1566.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":1566.060,"methodology":"fee schedule"}]}]},{"description":"Repair of graft-enteric fistula ","code_information":[{"code":"35870","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and la ","code_information":[{"code":"67043","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":9852.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":7390.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":9569.110,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":9764.400,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2984.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":9373.820,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":9569.110,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":9764.400,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) ","code_information":[{"code":"22614","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC ","code_information":[{"code":"152","type":"RC"},{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9629.410,"maximum":9629.410,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9629.410,"methodology":"fee schedule"}]}]},{"description":"Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"93567","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH ","code_information":[{"code":"121","type":"RC"},{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17087.530,"maximum":17087.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17087.530,"methodology":"fee schedule"}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS ","code_information":[{"code":"019","type":"MS-DRG"},{"code":"173","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":52426.960,"maximum":52426.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":52426.960,"methodology":"fee schedule"}]}]},{"description":"OTHER HEART ASSIST SYSTEM IMPLANT ","code_information":[{"code":"123","type":"RC"},{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":72547.200,"maximum":72547.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":72547.200,"methodology":"fee schedule"}]}]},{"description":"Mastoid obliteration (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"69670","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRN ","code_information":[{"code":"309","type":"RC"},{"code":"81430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1519.380,"maximum":1917.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1519.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1787.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1519.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1787.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1625.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1917.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1625.000,"methodology":"fee schedule"}]}]},{"description":"Lengthening of hamstring tendon; single tendon ","code_information":[{"code":"27393","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7649.030,"maximum":7649.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7649.030,"methodology":"fee schedule"}]}]},{"description":"Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes ","code_information":[{"code":"360","type":"RC"},{"code":"62267","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal ","code_information":[{"code":"26230","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Aortic suspension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate procedure) ","code_information":[{"code":"33800","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage catheterºs»/stentºs», when performed, and endoscopic ultrasound, when ","code_information":[{"code":"43240","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Copper cu 64 dotatate dia ","code_information":[{"code":"09383","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":576.450,"maximum":576.450,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":576.450,"methodology":"fee schedule"}]}]},{"description":"Blood count; spun microhematocrit ","code_information":[{"code":"85013","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6.540,"maximum":8.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.000,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular) ","code_information":[{"code":"27324","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"402","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":115.320,"maximum":1833.060,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":115.320,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1833.060,"methodology":"fee schedule"}]}]},{"description":"Meatotomy, cutting of meatus (separate procedure); except infant ","code_information":[{"code":"53020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":5015.140,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4914.840,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":5015.140,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4814.530,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":4914.840,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":5015.140,"methodology":"fee schedule"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; intermediate ","code_information":[{"code":"615","type":"RC"},{"code":"77285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":431.960,"maximum":431.960,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":431.960,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL74ZZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Repair of thoracoabdominal aortic aneurysm with graft, with or without cardiopulmonary bypass ","code_information":[{"code":"33877","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure) ","code_information":[{"code":"790","type":"RC"},{"code":"93567","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Excision of infected graft; abdomen ","code_information":[{"code":"35907","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant ","code_information":[{"code":"314","type":"RC"},{"code":"81258","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":375.250,"maximum":442.790,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":375.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":442.790,"methodology":"fee schedule"}]}]},{"description":"Coagulation time; activated ","code_information":[{"code":"301","type":"RC"},{"code":"85347","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.000,"maximum":5.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.710,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.280,"methodology":"fee schedule"}]}]},{"description":"Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations ","code_information":[{"code":"323","type":"RC"},{"code":"78414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.440,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":42.430,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":24.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Synovectomy, tendon sheath, foot; flexor ","code_information":[{"code":"28086","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7967.210,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"}]}]},{"description":"Floweramnioflo, 0.1 cc ","code_information":[{"code":"343","type":"RC"},{"code":"Q4177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":387.000,"maximum":387.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":387.000,"methodology":"fee schedule"}]}]},{"description":"Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed intra-amniotic ","code_information":[{"code":"480","type":"RC"},{"code":"59852","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Ova and parasites, direct smears, concentration and identification ","code_information":[{"code":"303","type":"RC"},{"code":"87177","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.320,"maximum":10.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.790,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.900,"methodology":"fee schedule"}]}]},{"description":"Blood count; blood smear, microscopic examination with manual differential WBC count ","code_information":[{"code":"85007","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3.550,"maximum":4.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.800,"methodology":"fee schedule"}]}]},{"description":"Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10°9 pfu/ml vector genomes, per 0.1 ml ","code_information":[{"code":"891","type":"RC"},{"code":"J3401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2181.800,"maximum":2181.800,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2181.800,"methodology":"fee schedule"}]}]},{"description":"Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diap ","code_information":[{"code":"58960","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"212","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27983.840,"maximum":27983.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27983.840,"methodology":"fee schedule"}]}]},{"description":"Repair of anal fistula with fibrin glue ","code_information":[{"code":"46706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":6947.360,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":6808.410,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":6947.360,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":6669.470,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":6808.410,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":6947.360,"methodology":"fee schedule"}]}]},{"description":"Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed ","code_information":[{"code":"362","type":"RC"},{"code":"43889","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COLONOSCOPY W/STENT ","code_information":[{"code":"45387","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":2755.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"124","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8748.290,"maximum":8748.290,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8748.290,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC ","code_information":[{"code":"515","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16222.830,"maximum":17560.800,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":17560.800,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":16222.830,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material ","code_information":[{"code":"324","type":"RC"},{"code":"70480","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":80.090,"maximum":97.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":80.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":90.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":80.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":97.400,"methodology":"fee schedule"}]}]},{"description":"Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc spac ","code_information":[{"code":"22853","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm ","code_information":[{"code":"23075","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection, non-radioactive, non-contrast, visualization adjunct (e.g., methylene blue, isosulfan blue), 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"Q9968","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21.090,"maximum":21.090,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.090,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, transrectal; ","code_information":[{"code":"400","type":"RC"},{"code":"76872","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"SPLENIC PROCEDURES WITH CC ","code_information":[{"code":"202","type":"RC"},{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21593.620,"maximum":21593.620,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21593.620,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm ","code_information":[{"code":"17266","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"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":"314","type":"RC"},{"code":"87324","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.980,"maximum":14.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"}]}]},{"description":"Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing ","code_information":[{"code":"369","type":"RC"},{"code":"47362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Fluoride ","code_information":[{"code":"309","type":"RC"},{"code":"82735","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.330,"maximum":21.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.390,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.540,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, chest; single view ","code_information":[{"code":"321","type":"RC"},{"code":"71045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.550,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.990,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":24.550,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":28.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Urinalysis; microscopic only ","code_information":[{"code":"311","type":"RC"},{"code":"81015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.050,"maximum":3.600,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.600,"methodology":"fee schedule"}]}]},{"description":"Anti-phosphatidylserine (phospholipid) antibody ","code_information":[{"code":"310","type":"RC"},{"code":"86148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.070,"maximum":18.960,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.960,"methodology":"fee schedule"}]}]},{"description":"Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed paraffin-embedded tissue ","code_information":[{"code":"0111U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":637.940,"maximum":805.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":637.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":750.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":637.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":750.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":805.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":682.290,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of coccygeal fracture ","code_information":[{"code":"27200","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection, partial or complete, phalangeal base, each toe ","code_information":[{"code":"28126","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"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":"324","type":"RC"},{"code":"75774","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":131.770,"maximum":160.250,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":131.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":149.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":131.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":160.250,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":133.620,"methodology":"fee schedule"}]}]},{"description":"Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List sep ","code_information":[{"code":"362","type":"RC"},{"code":"67332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"309","type":"RC"},{"code":"87427","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.200,"maximum":14.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.980,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, head; without contrast material(s) ","code_information":[{"code":"401","type":"RC"},{"code":"70544","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"58100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Myoglobin ","code_information":[{"code":"83874","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.070,"maximum":22.490,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":11.630,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":13.050,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":11.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":11.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":11.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":11.630,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":13.570,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":13.310,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":13.570,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":22.490,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":19.380,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":13.570,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":13.570,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":12.530,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":15.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":13.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":13.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":11.070,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":19.380,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.570,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":13.180,"methodology":"fee schedule"}]}]},{"description":"Interthoracoscapular amputation (forequarter) ","code_information":[{"code":"23900","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Technetium tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries ","code_information":[{"code":"892","type":"RC"},{"code":"A9560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":234.110,"maximum":234.110,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":234.110,"methodology":"fee schedule"}]}]},{"description":"Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation ","code_information":[{"code":"369","type":"RC"},{"code":"44602","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC BRAIN INJURY; M > 44.25 & C < 23.5 ","code_information":[{"code":"128","type":"RC"},{"code":"D0203","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19570.020,"maximum":22394.550,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21385.790,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20175.270,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":22394.550,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21184.040,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":19570.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20377.030,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20377.030,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20377.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20175.270,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":22394.550,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":22394.550,"methodology":"fee schedule"}]}]},{"description":"Bone and/or joint imaging; 3 phase study ","code_information":[{"code":"342","type":"RC"},{"code":"78315","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":426.700,"maximum":848.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":426.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":484.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":426.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":491.890,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS ","code_information":[{"code":"204","type":"RC"},{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21160.900,"maximum":21160.900,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21160.900,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, tarsal bones, other than calcaneus or talus; ","code_information":[{"code":"28304","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Salivary gland imaging; with serial images ","code_information":[{"code":"324","type":"RC"},{"code":"78231","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":167.050,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":167.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous ","code_information":[{"code":"481","type":"RC"},{"code":"50390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Trabeculotomy ab externo ","code_information":[{"code":"65850","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC; M > 38.55 & M < 48.85 ","code_information":[{"code":"118","type":"RC"},{"code":"B1402","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":22255.850,"maximum":25468.030,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":24320.830,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22944.180,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25468.030,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":24091.380,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":22255.850,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23173.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":23173.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":23173.620,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22944.180,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":25468.030,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":25468.030,"methodology":"fee schedule"}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization ","code_information":[{"code":"362","type":"RC"},{"code":"42971","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES ","code_information":[{"code":"0304","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":42654.130,"maximum":63981.190,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":42654.130,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":43507.210,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":63981.190,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":42654.130,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":42654.130,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":42654.130,"methodology":"fee schedule"}]}]},{"description":"Tonsillectomy, primary or secondary; age 12 or over ","code_information":[{"code":"360","type":"RC"},{"code":"42826","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance angiography, head; without contrast material(s) ","code_information":[{"code":"618","type":"RC"},{"code":"70544","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; each additional 25 sq cm of harvested skin or part thereo ","code_information":[{"code":"15014","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach ","code_information":[{"code":"360","type":"RC"},{"code":"54520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"73718","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":227.190,"maximum":276.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":227.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":257.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":227.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":276.300,"methodology":"fee schedule"}]}]},{"description":"Urography, antegrade, radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"74425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Hepatitis B core antibody (HBcAb); IgM antibody ","code_information":[{"code":"314","type":"RC"},{"code":"86705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.770,"maximum":13.890,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.890,"methodology":"fee schedule"}]}]},{"description":"Tenolysis, extensor, foot; single tendon ","code_information":[{"code":"28225","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum ","code_information":[{"code":"319","type":"RC"},{"code":"87300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.980,"maximum":14.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when ","code_information":[{"code":"37295","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Ensifentrine, inhalation suspension, fda approved final product, non-compounded, administered through dme, unit dose form, 3 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J7601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":112.060,"maximum":112.060,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":112.060,"methodology":"fee schedule"}]}]},{"description":"Antepartum care only; 7 or more visits ","code_information":[{"code":"481","type":"RC"},{"code":"59426","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7027.200,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries ","code_information":[{"code":"361","type":"RC"},{"code":"61711","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"IDH1 (isocitrate dehydrogenase 1 ºNADP+», soluble) (eg, glioma), common variants (eg, R132H, R132C) ","code_information":[{"code":"300","type":"RC"},{"code":"81120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":180.690,"maximum":228.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":228.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":193.250,"methodology":"fee schedule"}]}]},{"description":"Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"75891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":147.990,"maximum":147.990,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":147.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":147.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":147.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":147.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":147.990,"methodology":"fee schedule"}]}]},{"description":"Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging ","code_information":[{"code":"480","type":"RC"},{"code":"51798","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension ","code_information":[{"code":"24538","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RECTAL RESECTION WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"333","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18263.060,"maximum":18263.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18263.060,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by ","code_information":[{"code":"35011","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lengthening of palate, with island flap ","code_information":[{"code":"42227","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography ","code_information":[{"code":"23350","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of talus fracture; without manipulation ","code_information":[{"code":"28430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":603.240,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":615.800,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":628.370,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":603.240,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":615.800,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":628.370,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm ","code_information":[{"code":"21557","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators ","code_information":[{"code":"321","type":"RC"},{"code":"77610","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":94.010,"maximum":114.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":94.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":106.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":94.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":114.330,"methodology":"fee schedule"}]}]},{"description":"Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time ","code_information":[{"code":"401","type":"RC"},{"code":"76000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of mandibular fracture; with manipulation ","code_information":[{"code":"21451","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"74177","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":350.520,"maximum":511.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":420.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":476.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":420.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":511.080,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":424.010,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":350.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Spectrophotometry, analyte not elsewhere specified ","code_information":[{"code":"319","type":"RC"},{"code":"84311","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.100,"maximum":9.560,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.100,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.560,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"117","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8418.940,"maximum":8418.940,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8418.940,"methodology":"fee schedule"}]}]},{"description":"Burr hole(s) or trephine; with drainage of brain abscess or cyst ","code_information":[{"code":"481","type":"RC"},{"code":"61150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"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":"300","type":"RC"},{"code":"81536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":166.020,"maximum":209.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":166.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":195.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":166.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":195.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":177.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":209.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":177.560,"methodology":"fee schedule"}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITHOUT MCC* ","code_information":[{"code":"055","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4336.590,"maximum":4694.250,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":4694.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":4336.590,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"210","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6372.270,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6372.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Transfer, finger to another position without microvascular anastomosis ","code_information":[{"code":"26555","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22327.170,"maximum":22327.170,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22327.170,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; ","code_information":[{"code":"320","type":"RC"},{"code":"75557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":474.190,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":389.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":442.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":389.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":474.190,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":411.730,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":323.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) ","code_information":[{"code":"27698","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13477.510,"maximum":13477.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13477.510,"methodology":"fee schedule"}]}]},{"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":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2992.000,"maximum":3776.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2992.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3520.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2992.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3520.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3200.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3776.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3200.000,"methodology":"fee schedule"}]}]},{"description":"Repair of blepharoptosis; (tarso) levator resection or advancement, external approach ","code_information":[{"code":"67904","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (List separately in addition to code for primary procedure) ","code_information":[{"code":"0570T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":77821.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":70843.780,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":25929.980,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":70843.780,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":70843.780,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":70843.780,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":50602.700,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":63977.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":72575.500,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":26443.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":63977.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":77821.800,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":32091.560,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":26186.720,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":21822.260,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":21822.260,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":26186.720,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":26186.720,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":33519.730,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":26700.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":38540.320,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":26700.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":24903.050,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":28905.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25929.980,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":25929.980,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":25929.980,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":25673.250,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":25673.250,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":25673.250,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":34203.810,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":35829.260,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":29530.140,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":35488.950,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":27182.730,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":26700.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":32835.660,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":26700.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":33519.730,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":38509.880,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":26956.910,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":25673.250,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":34203.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":25673.250,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":25673.250,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":26186.720,"methodology":"fee schedule"}]}]},{"description":"Glucagon tolerance panel; for insulinoma This panel must include the following: Glucose (82947 x 3) Insulin (83525 x 3) ","code_information":[{"code":"319","type":"RC"},{"code":"80422","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46.070,"maximum":54.360,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":46.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":54.360,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST PROCEDURES WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33515.770,"maximum":33515.770,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33515.770,"methodology":"fee schedule"}]}]},{"description":"Volatiles (eg, acetic anhydride, diethylether) ","code_information":[{"code":"304","type":"RC"},{"code":"84600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.000,"maximum":20.190,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.110,"methodology":"fee schedule"}]}]},{"description":"Colectomy, partial, with removal of terminal ileum with ileocolostomy ","code_information":[{"code":"44160","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Laminectomy with rhizotomy; 1 or 2 segments ","code_information":[{"code":"63185","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, urine, 31 drug panel, reported as quantitative results, detected or not-detected, per date of service ","code_information":[{"code":"0051U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":203.400,"maximum":370.380,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":249.390,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":203.400,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":254.330,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":251.860,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":259.270,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":251.860,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":370.380,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":259.270,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":259.270,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":239.510,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":232.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":249.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":249.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":249.390,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":370.380,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":259.270,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":251.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":251.860,"methodology":"fee schedule"}]}]},{"description":"Pulmonary disease (idiopathic pulmonary fibrosis ºIPF»), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positi ","code_information":[{"code":"314","type":"RC"},{"code":"81554","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5409.600,"maximum":6383.330,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5409.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6383.330,"methodology":"fee schedule"}]}]},{"description":"Injection, phytonadione (vitamin k), per 1 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J3430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6.040,"maximum":6.040,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.040,"methodology":"fee schedule"}]}]},{"description":"OSTEOARTHRITIS; M > 37.65 ","code_information":[{"code":"128","type":"RC"},{"code":"B1201","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20709.700,"maximum":23698.730,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":22631.220,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":21350.200,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":23698.730,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":22417.710,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":20709.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21563.710,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":21563.710,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":21563.710,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":21350.200,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":23698.730,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":23698.730,"methodology":"fee schedule"}]}]},{"description":"Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheter ","code_information":[{"code":"36253","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Plastic repair of urethrocele ","code_information":[{"code":"369","type":"RC"},{"code":"57230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Technetium tc-99m succimer, diagnostic, per study dose, up to 10 millicuries ","code_information":[{"code":"344","type":"RC"},{"code":"A9551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1418.850,"maximum":1418.850,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1418.850,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space ","code_information":[{"code":"63172","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":4950.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array ","code_information":[{"code":"481","type":"RC"},{"code":"64584","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Venous thrombosis imaging, venogram; unilateral ","code_information":[{"code":"78457","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":269.640,"maximum":269.640,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":269.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":269.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":269.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":269.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":269.640,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH PTCA WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":61660.850,"maximum":61660.850,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":61660.850,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC ","code_information":[{"code":"219","type":"RC"},{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9629.410,"maximum":9629.410,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9629.410,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, clavicle, with or without internal fixation; ","code_information":[{"code":"23480","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Tenodesis; of distal joint, each joint ","code_information":[{"code":"26474","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"43212","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) ","code_information":[{"code":"43247","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification ","code_information":[{"code":"304","type":"RC"},{"code":"87652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.050,"maximum":49.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":39.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":45.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":39.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":49.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":41.760,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24326.780,"maximum":24326.780,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24326.780,"methodology":"fee schedule"}]}]},{"description":"AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC ","code_information":[{"code":"016","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":43837.510,"maximum":43837.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":43837.510,"methodology":"fee schedule"}]}]},{"description":"Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis ","code_information":[{"code":"0170U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1891.500,"maximum":2925.000,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1969.500,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":2047.500,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":2008.500,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":1989.000,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":2047.500,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":1989.000,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":2925.000,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":2047.500,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":2047.500,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":1891.500,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2106.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1969.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":1969.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":1969.500,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":2925.000,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":2047.500,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1989.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":1950.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":1989.000,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) ","code_information":[{"code":"21247","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NEC ","code_information":[{"code":"004","type":"MS-DRG"},{"code":"121","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":100309.470,"maximum":100309.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":100309.470,"methodology":"fee schedule"}]}]},{"description":"Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware ","code_information":[{"code":"E2373","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":96.520,"maximum":149.270,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":100.510,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":102.500,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":104.490,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":101.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":99.510,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":104.490,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":104.490,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":96.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":100.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":100.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":100.510,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":99.510,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":99.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":99.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":96.520,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":149.270,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":104.490,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":99.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":101.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":99.510,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":101.500,"methodology":"fee schedule"}]}]},{"description":"Plasma cryo redu path eac ","code_information":[{"code":"09538","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":129.750,"maximum":129.750,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":129.750,"methodology":"fee schedule"}]}]},{"description":"Therapeutic apheresis; for white blood cells ","code_information":[{"code":"36511","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pharyngolaryngectomy, with radical neck dissection; with reconstruction ","code_information":[{"code":"31395","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) ","code_information":[{"code":"20924","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) ","code_information":[{"code":"44143","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11773.740,"maximum":11773.740,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11773.740,"methodology":"fee schedule"}]}]},{"description":"Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performed ","code_information":[{"code":"27065","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hepatitis b screening in non-pregnant, high risk individual includes hepatitis b surface antigen (hbsag), antibodies to hbsag (anti-hbs) and antibodies to hepatitis b core antigen (anti-hbc), and is f ","code_information":[{"code":"301","type":"RC"},{"code":"G0499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":26.430,"maximum":33.360,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":26.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":31.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":26.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":28.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":33.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28.270,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, ","code_information":[{"code":"361","type":"RC"},{"code":"43277","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) ","code_information":[{"code":"38900","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of cervical stump, abdominal approach; ","code_information":[{"code":"57540","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each ","code_information":[{"code":"369","type":"RC"},{"code":"44721","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis; subtalar ","code_information":[{"code":"28725","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN BODY ","code_information":[{"code":"62163","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11891.200,"maximum":11891.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; quantitative A-scan only ","code_information":[{"code":"402","type":"RC"},{"code":"76511","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":48.190,"maximum":58.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":48.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":54.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":48.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":58.600,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with sphenoidotomy; ","code_information":[{"code":"31287","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Tricuspid valve repositioning and plication for Ebstein anomaly ","code_information":[{"code":"33468","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"211","type":"RC"},{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14159.020,"maximum":14159.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14159.020,"methodology":"fee schedule"}]}]},{"description":"Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene ","code_information":[{"code":"0009U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":100.050,"maximum":126.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":100.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":117.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":100.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":117.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":107.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":126.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":107.000,"methodology":"fee schedule"}]}]},{"description":"Cholecystoenterostomy; Roux-en-Y ","code_information":[{"code":"369","type":"RC"},{"code":"47740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Proctectomy; complete, combined abdominoperineal, with colostomy ","code_information":[{"code":"45110","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, ","code_information":[{"code":"499","type":"RC"},{"code":"58943","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Carbamazepine; total ","code_information":[{"code":"319","type":"RC"},{"code":"80156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.570,"maximum":17.190,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.190,"methodology":"fee schedule"}]}]},{"description":"Removal or revision of sling for stress incontinence (eg, fascia or synthetic) ","code_information":[{"code":"481","type":"RC"},{"code":"57287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":" Behavioral Health Treatment/Services Individual Therapy  ","code_information":[{"code":"914","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":77.000,"maximum":125.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":125.000,"methodology":"case rate"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":77.000,"methodology":"case rate"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21521.610,"maximum":21521.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21521.610,"methodology":"fee schedule"}]}]},{"description":"PAIN SYNDROME: M < 26.75 ","code_information":[{"code":"128","type":"RC"},{"code":"C1603","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":21460.110,"maximum":24557.440,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":23451.250,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22123.820,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":24557.440,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":23230.010,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":21460.110,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22345.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":22345.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":22345.060,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22123.820,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":24557.440,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":24557.440,"methodology":"fee schedule"}]}]},{"description":"Adrenal imaging, cortex and/or medulla ","code_information":[{"code":"340","type":"RC"},{"code":"78075","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":46.160,"maximum":53.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":46.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":52.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":46.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":53.210,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"143","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":28274.700,"maximum":28274.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28274.700,"methodology":"fee schedule"}]}]},{"description":"Open treatment of orbital floor blowout fracture; periorbital approach ","code_information":[{"code":"21386","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urethroplasty for second stage hypospadias repair (including urinary diversion); greater than 3 cm ","code_information":[{"code":"360","type":"RC"},{"code":"54312","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Open osteochondral autograft, talus (includes obtaining graftºs») ","code_information":[{"code":"28446","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Synovectomy, tendon sheath, foot; extensor ","code_information":[{"code":"28088","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or ","code_information":[{"code":"27216","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11773.740,"maximum":11773.740,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11773.740,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); with cont ","code_information":[{"code":"619","type":"RC"},{"code":"70558","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":401.740,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disrupti ","code_information":[{"code":"321","type":"RC"},{"code":"75958","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":222.630,"maximum":380.090,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":380.090,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":222.630,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Tau, phosphorylated (eg, pTau 181, pTau 217), each ","code_information":[{"code":"314","type":"RC"},{"code":"84393","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.920,"maximum":152.130,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":128.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":152.130,"methodology":"fee schedule"}]}]},{"description":"Blood count; red blood cell (RBC), automated ","code_information":[{"code":"312","type":"RC"},{"code":"85041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.020,"maximum":3.560,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3.020,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.560,"methodology":"fee schedule"}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS ","code_information":[{"code":"019","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":52426.960,"maximum":52426.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":52426.960,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C ","code_information":[{"code":"190","type":"RC"},{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Cephalogram, orthodontic ","code_information":[{"code":"321","type":"RC"},{"code":"70350","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":11.800,"maximum":14.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.350,"methodology":"fee schedule"}]}]},{"description":"Cardiac ion channelopathies, genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic re ","code_information":[{"code":"0237U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":546.880,"maximum":690.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":546.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":643.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":546.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":643.390,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":584.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":690.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":584.900,"methodology":"fee schedule"}]}]},{"description":"Urethrectomy, total, including cystostomy; female ","code_information":[{"code":"481","type":"RC"},{"code":"53210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Guided tissue regeneration, edentulous area - non-resorbably barrier, per site ","code_information":[{"code":"361","type":"RC"},{"code":"D7957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection, phenylephrine hydrochloride (biorphen), 20 micrograms ","code_information":[{"code":"891","type":"RC"},{"code":"J2372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.340,"maximum":0.340,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.340,"methodology":"fee schedule"}]}]},{"description":"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE ","code_information":[{"code":"7703","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4513.330,"maximum":6769.990,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":4513.330,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":4603.600,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":6769.990,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":4513.330,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":4513.330,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":4513.330,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9593.760,"maximum":9593.760,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9593.760,"methodology":"fee schedule"}]}]},{"description":"Anorectal manometry, with rectal sensation and rectal balloon expulsion test, when performed ","code_information":[{"code":"323","type":"RC"},{"code":"91125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":484.390,"maximum":589.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":484.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":549.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":484.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":589.090,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thorax, diagnostic; without contrast material ","code_information":[{"code":"71250","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":267.420,"maximum":278.560,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":272.990,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":278.560,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":267.420,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":272.990,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":278.560,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, eye, for detection of foreign body ","code_information":[{"code":"611","type":"RC"},{"code":"70030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Valproic acid (dipropylacetic acid); free ","code_information":[{"code":"300","type":"RC"},{"code":"80165","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.660,"maximum":15.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.890,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.540,"methodology":"fee schedule"}]}]},{"description":"HEADACHES WITH MCC ","code_information":[{"code":"102","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9556.690,"maximum":9556.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9556.690,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy through stoma; with control of bleeding, any method ","code_information":[{"code":"361","type":"RC"},{"code":"44391","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Dilation of female urethra including suppository and/or instillation; subsequent ","code_information":[{"code":"53661","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2992.000,"maximum":3776.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2992.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3520.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2992.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3520.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3200.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3776.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3200.000,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, teeth; complete, full mouth ","code_information":[{"code":"342","type":"RC"},{"code":"70320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8051.810,"maximum":8051.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8051.810,"methodology":"fee schedule"}]}]},{"description":"Esano aaa, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"302","type":"RC"},{"code":"81343","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Syphilis test, non-treponemal antibody, immunoassay, qualitative (RPR) ","code_information":[{"code":"0065U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16.910,"maximum":21.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.900,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.090,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body ","code_information":[{"code":"29894","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Neuro Muscular Dystrophy Dmd Seq Alys Bld/Saliva ","code_information":[{"code":"0218U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2130.870,"maximum":2689.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2130.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2506.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2130.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2506.900,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2689.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2279.000,"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, splenic arte ","code_information":[{"code":"35111","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH CC ","code_information":[{"code":"191","type":"RC"},{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision, prepatellar bursa ","code_information":[{"code":"27340","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, open, hamstring, knee to hip; single tendon ","code_information":[{"code":"27390","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Impression and custom preparation; surgical obturator prosthesis ","code_information":[{"code":"21076","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Amniocentesis; diagnostic ","code_information":[{"code":"59000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2189.660,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":2235.280,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":2280.900,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2189.660,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":2235.280,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":2280.900,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19»), influenza virus types A and B, and respiratory s ","code_information":[{"code":"303","type":"RC"},{"code":"87637","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":133.430,"maximum":168.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":133.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":156.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":133.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":156.980,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":168.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":142.710,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views ","code_information":[{"code":"400","type":"RC"},{"code":"71101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":58.250,"maximum":245.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":58.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":66.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":58.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":70.840,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization ","code_information":[{"code":"42971","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC ","code_information":[{"code":"002","type":"MS-DRG"},{"code":"02WA4RZ","type":"ICD"}],"standard_charges":[{"setting":"inpatient","minimum":253707.000,"maximum":253707.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":253707.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 20. "}]}]},{"description":"Computed tomography, maxillofacial area; with contrast material(s) ","code_information":[{"code":"70487","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":207.820,"maximum":207.820,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":207.820,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":207.820,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":207.820,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":207.820,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":207.820,"methodology":"fee schedule"}]}]},{"description":"RHEUMATOID, OTHER ARTHRITIS; M > 26.15 & M < 36.35 ","code_information":[{"code":"B1302","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":24235.860,"maximum":25250.840,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":24755.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24235.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":24755.730,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":25250.840,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette ","code_information":[{"code":"319","type":"RC"},{"code":"85461","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.360,"maximum":11.040,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.360,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.040,"methodology":"fee schedule"}]}]},{"description":"Nuclear Matrix Protein 22 (NMP22), qualitative ","code_information":[{"code":"310","type":"RC"},{"code":"86386","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.780,"maximum":25.700,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":25.700,"methodology":"fee schedule"}]}]},{"description":"Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) ","code_information":[{"code":"13133","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Ovulation tests, by visual color comparison methods for human luteinizing hormone ","code_information":[{"code":"305","type":"RC"},{"code":"84830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.870,"maximum":14.990,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.970,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.700,"methodology":"fee schedule"}]}]},{"description":"Oncology (breast cancer), DNA, PIK3CA gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status ","code_information":[{"code":"0177U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Repair of double outlet right ventricle with intraventricular tunnel repair; ","code_information":[{"code":"33611","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction ","code_information":[{"code":"27502","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12140.880,"maximum":12140.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12140.880,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL ","code_information":[{"code":"112","type":"RC"},{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":49197.640,"maximum":49197.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":49197.640,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6040.790,"maximum":6040.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6040.790,"methodology":"fee schedule"}]}]},{"description":"Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and ","code_information":[{"code":"95923","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":324.140,"maximum":337.650,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":330.900,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":337.650,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":324.140,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":330.900,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":337.650,"methodology":"fee schedule"}]}]},{"description":"Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption ","code_information":[{"code":"43847","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision ","code_information":[{"code":"31084","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6342.330,"maximum":6342.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6342.330,"methodology":"fee schedule"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity ","code_information":[{"code":"304","type":"RC"},{"code":"83861","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.020,"maximum":26.530,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.730,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.480,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.480,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13001.310,"maximum":13001.310,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13001.310,"methodology":"fee schedule"}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE ","code_information":[{"code":"137","type":"RC"},{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":42196.470,"maximum":42196.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":42196.470,"methodology":"fee schedule"}]}]},{"description":"Drainage of palmar bursa; multiple bursa ","code_information":[{"code":"26030","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PREMATURITY WITHOUT MAJOR PROBLEMS ","code_information":[{"code":"152","type":"RC"},{"code":"792","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19025.830,"maximum":19025.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19025.830,"methodology":"fee schedule"}]}]},{"description":"Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer, hereditary pancreatic cancer, hereditary prostate cancer), genomic s ","code_information":[{"code":"307","type":"RC"},{"code":"81432","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":634.910,"maximum":1538.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":634.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":746.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":634.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":746.960,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1303.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1538.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":679.050,"methodology":"fee schedule"}]}]},{"description":"Proton treatment delivery; simple, without compensation ","code_information":[{"code":"329","type":"RC"},{"code":"77520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.600,"maximum":682.600,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"401","type":"RC"},{"code":"72130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"212","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13195.930,"maximum":13195.930,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13195.930,"methodology":"fee schedule"}]}]},{"description":"Amino acids; single, quantitative, each specimen ","code_information":[{"code":"314","type":"RC"},{"code":"82131","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.980,"maximum":27.120,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.120,"methodology":"fee schedule"}]}]},{"description":"Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75746","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":150.800,"maximum":6438.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":186.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":211.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":186.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":227.160,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":184.750,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":150.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6438.740,"methodology":"fee schedule"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"122","type":"MS-DRG"},{"code":"173","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7167.840,"maximum":7167.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7167.840,"methodology":"fee schedule"}]}]},{"description":"Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"66825","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":32816.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":29874.140,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":11773.620,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":29874.140,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":29874.140,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":29874.140,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":21338.670,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":26978.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30604.390,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":12006.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":26978.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32816.700,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":14571.310,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":11890.190,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":9908.490,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":9908.490,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":11890.190,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":11890.190,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":15603.930,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":12123.330,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16252.080,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":12123.330,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":11307.340,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":12189.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11773.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":11773.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":11773.620,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":11657.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":11657.050,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":11657.050,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":15922.380,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":16679.050,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":13746.720,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":16520.630,"methodology":"fee schedule"},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":12653.960,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":12123.330,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10744.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":15285.480,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":12123.330,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":15603.930,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":17485.570,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12239.900,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":11657.050,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":15922.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10391.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11412.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":11657.050,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":11657.050,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":11890.190,"methodology":"fee schedule"}]}]},{"description":"Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code) ","code_information":[{"code":"15854","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for prima ","code_information":[{"code":"15152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Clotting; factor VII (proconvertin, stable factor) ","code_information":[{"code":"306","type":"RC"},{"code":"85230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.740,"maximum":21.120,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.690,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.900,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum ","code_information":[{"code":"303","type":"RC"},{"code":"87300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.200,"maximum":14.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.980,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA WITH BRAIN OR SPINAL CORD IN ","code_information":[{"code":"024","type":"RC"},{"code":"B1803","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":28517.440,"maximum":28517.440,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":28517.440,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"573","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":48269.460,"maximum":48269.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":48269.460,"methodology":"fee schedule"}]}]},{"description":"Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"11107","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, glucagon (gvoke), 0.01 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.590,"maximum":5.590,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.590,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, arthroscopy ","code_information":[{"code":"29999","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":12724.600,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16487.990,"maximum":16487.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16487.990,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21054.680,"maximum":21054.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21054.680,"methodology":"fee schedule"}]}]},{"description":"Removal foreign body, intranasal; requiring general anesthesia ","code_information":[{"code":"30310","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"AFTERCARE WITH CC/MCC ","code_information":[{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3811.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3811.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"RHEUMATOID, OTHER ARTHRITIS; M > 36.35 ","code_information":[{"code":"118","type":"RC"},{"code":"D1301","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":14345.300,"maximum":16415.760,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":15676.310,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":14788.970,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":16415.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":15528.420,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":14345.300,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14936.860,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":14936.860,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":14936.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":14788.970,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":16415.760,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":16415.760,"methodology":"fee schedule"}]}]},{"description":"Trabeculotomy ab externo ","code_information":[{"code":"360","type":"RC"},{"code":"65850","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) ","code_information":[{"code":"303","type":"RC"},{"code":"85027","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.050,"maximum":7.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.120,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.470,"methodology":"fee schedule"}]}]},{"description":"Injection, gamma globulin, intramuscular, 1 cc ","code_information":[{"code":"344","type":"RC"},{"code":"J1460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":107.330,"maximum":107.330,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":107.330,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"213","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9885.330,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9885.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Colonoscopy, flexible; with removal of foreign body(s) ","code_information":[{"code":"45379","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap) ","code_information":[{"code":"361","type":"RC"},{"code":"39561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11066.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip ","code_information":[{"code":"30400","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Closure of intestinal cutaneous fistula ","code_information":[{"code":"44640","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Clitoroplasty for intersex state ","code_information":[{"code":"56805","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy with rhizotomy; more than 2 segments ","code_information":[{"code":"63190","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Vestibuloplasty; posterior, bilateral ","code_information":[{"code":"360","type":"RC"},{"code":"40843","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision) ","code_information":[{"code":"480","type":"RC"},{"code":"52346","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Injection, pertuzumab, 1 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J9306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":36.570,"maximum":36.570,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36.570,"methodology":"fee schedule"}]}]},{"description":"Surrogate viral neutralization test (sVNT), severe acute respiratory s yndrome coronavirus 2 (SARS-CoV-2) (Corornavirus disease (COVID-19)), ( ELISA, plasma, serum ","code_information":[{"code":"0226U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":39.480,"maximum":49.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":39.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":46.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":39.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":46.440,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":42.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":49.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":42.220,"methodology":"fee schedule"}]}]},{"description":"Biopsy of epididymis, needle ","code_information":[{"code":"369","type":"RC"},{"code":"54800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected ","code_information":[{"code":"0017U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":85.700,"maximum":108.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":85.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":100.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":85.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":100.830,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":91.660,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":108.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":91.660,"methodology":"fee schedule"}]}]},{"description":"Repair of pulmonary artery stenosis by reconstruction with patch or graft ","code_information":[{"code":"33917","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, upper extremity; with contrast material(s) ","code_information":[{"code":"341","type":"RC"},{"code":"73201","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body, intraocular; from anterior chamber of eye or lens ","code_information":[{"code":"367","type":"RC"},{"code":"65235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, biliary tract ","code_information":[{"code":"367","type":"RC"},{"code":"47999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23098.510,"maximum":23098.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23098.510,"methodology":"fee schedule"}]}]},{"description":"Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other pro ","code_information":[{"code":"361","type":"RC"},{"code":"49595","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Injection, linezolid (hospira), not therapeutically equivalent to j2020, 200 mg ","code_information":[{"code":"J2021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6.150,"maximum":23.560,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":23.560,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":7.230,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":10.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":6.150,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":7.090,"methodology":"fee schedule"}]}]},{"description":"NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN BODY ","code_information":[{"code":"480","type":"RC"},{"code":"62163","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11891.200,"maximum":11891.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Creation of pericardial window or partial resection for drainage ","code_information":[{"code":"33025","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":11888.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Acetylcholine receptor (AChR); binding antibody ","code_information":[{"code":"300","type":"RC"},{"code":"86041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.200,"maximum":21.710,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.400,"methodology":"fee schedule"}]}]},{"description":"Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture ","code_information":[{"code":"15920","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same v ","code_information":[{"code":"361","type":"RC"},{"code":"37231","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3162.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":25632.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":4135.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3435.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":4096.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10615.310,"maximum":10615.310,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10615.310,"methodology":"fee schedule"}]}]},{"description":"Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow h ","code_information":[{"code":"0265T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC ","code_information":[{"code":"204","type":"RC"},{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20367.470,"maximum":20367.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20367.470,"methodology":"fee schedule"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius ","code_information":[{"code":"25151","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Proctosigmoidoscopy, rigid; with removal of foreign body ","code_information":[{"code":"45307","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; double-contrast (eg, high density barium and air) study, including glucagon, when administe ","code_information":[{"code":"329","type":"RC"},{"code":"74280","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":78.240,"maximum":95.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":78.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":88.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":78.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":95.150,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and a ","code_information":[{"code":"369","type":"RC"},{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":26780.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13647.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15481.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13647.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16600.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":16014.100,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26780.000,"methodology":"case rate"}]}]},{"description":"Incision of lingual frenum (frenotomy) ","code_information":[{"code":"41010","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"27894","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, amphotericin b liposome, 10 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J0289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":44.550,"maximum":44.550,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":44.550,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"194","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Infectious disease (bacterial or viral), 32 genes (29 informative and 3 housekeeping), immune response mRNA, gene expression profiling by splitwell multiplex infection ","code_information":[{"code":"0588U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":710.600,"maximum":896.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, elbow, arthrography, radiological supervision and interpretation ","code_information":[{"code":"401","type":"RC"},{"code":"73085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Bone and/or joint imaging; limited area ","code_information":[{"code":"322","type":"RC"},{"code":"78300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":230.930,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":400.850,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":230.930,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"DELIVERY COMP IMRT ","code_information":[{"code":"0073T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":1496.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"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":"329","type":"RC"},{"code":"75574","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":304.650,"maximum":370.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":304.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":345.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":304.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":370.500,"methodology":"fee schedule"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad ","code_information":[{"code":"15838","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Lipoprotein-associated phospholipase A2 (Lp-PLA2) ","code_information":[{"code":"309","type":"RC"},{"code":"83698","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":43.300,"maximum":54.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":46.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":54.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":46.310,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation ","code_information":[{"code":"352","type":"RC"},{"code":"76813","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8557.240,"maximum":8557.240,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8557.240,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous ","code_information":[{"code":"33946","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Surgery of intracranial arteriovenous malformation; dural, simple ","code_information":[{"code":"369","type":"RC"},{"code":"61690","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Amputation, foot; transmetatarsal ","code_information":[{"code":"28805","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Intraoperative radiation treatment delivery, x-ray, single treatment session ","code_information":[{"code":"404","type":"RC"},{"code":"77424","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9020.500,"maximum":9020.500,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9020.500,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic ","code_information":[{"code":"63286","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic ","code_information":[{"code":"22206","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"128","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10472.600,"maximum":12738.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Oncology (prostate cancer), analysis of all prostate-specific antigen (psa) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer ","code_information":[{"code":"0359U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":710.600,"maximum":896.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"111","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"Bilirubin; direct ","code_information":[{"code":"314","type":"RC"},{"code":"82248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.020,"maximum":5.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.020,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.920,"methodology":"fee schedule"}]}]},{"description":"FIXATION OF TONGUE, MECHANICAL, OTHER THAN SUTURE (EG, K-WIRE) ","code_information":[{"code":"41500","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4635.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4635.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"204","type":"RC"},{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11723.120,"maximum":11723.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11723.120,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION ","code_information":[{"code":"5394","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11760.080,"maximum":17640.120,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":11760.080,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":11995.280,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":17640.120,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":11760.080,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":11760.080,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":11760.080,"methodology":"fee schedule"}]}]},{"description":"Radial keratotomy ","code_information":[{"code":"361","type":"RC"},{"code":"65771","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION, NON-LOWER EXTREMITY; M > 36.35 ","code_information":[{"code":"148","type":"RC"},{"code":"A1101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":15072.260,"maximum":17247.630,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":16470.710,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":15538.410,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":17247.630,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":16315.330,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":15072.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15693.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":15693.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":15693.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":15538.410,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":17247.630,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":17247.630,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26312.860,"maximum":26312.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26312.860,"methodology":"fee schedule"}]}]},{"description":"Graft; derma-fat-fascia ","code_information":[{"code":"15770","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Excision or curettage of bone cyst or benign tumor of femur; ","code_information":[{"code":"27355","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Abo Gnotyp Gene Alys Next-Generation Seq Abo Gen ","code_information":[{"code":"0221U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each ","code_information":[{"code":"344","type":"RC"},{"code":"90284","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":51.990,"maximum":51.990,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":51.990,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9261.560,"maximum":9261.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9261.560,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code ","code_information":[{"code":"362","type":"RC"},{"code":"36248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review an ","code_information":[{"code":"93285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"NAP","standard_charge_percentage":55.13,"standard_charge_algorithm":"Reimbursement will be 55.13% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"OpenAccess","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"POS","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"QualifiedHealthPlan","standard_charge_percentage":25.86,"standard_charge_algorithm":"Reimbursement will be 25.86% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"212","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24092.970,"maximum":24092.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24092.970,"methodology":"fee schedule"}]}]},{"description":"Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral ","code_information":[{"code":"329","type":"RC"},{"code":"77065","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":122.120,"maximum":148.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":122.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":138.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":122.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":148.510,"methodology":"fee schedule"}]}]},{"description":"Xenograft implantation into the articular surface ","code_information":[{"code":"0737T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation) ","code_information":[{"code":"25275","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) ","code_information":[{"code":"309","type":"RC"},{"code":"81275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":180.690,"maximum":228.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":228.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":193.250,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24262.630,"maximum":24262.630,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24262.630,"methodology":"fee schedule"}]}]},{"description":"Repair, dislocating peroneal tendons; with fibular osteotomy ","code_information":[{"code":"27676","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13919.500,"maximum":13919.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13919.500,"methodology":"fee schedule"}]}]},{"description":"Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular ","code_information":[{"code":"27429","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography ºOCT»), posterior segment, with interpretation and report, unilateral or bilateral; retina, including OCT angiography ","code_information":[{"code":"329","type":"RC"},{"code":"92137","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":700.650,"maximum":700.650,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":700.650,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of; facial nerve, differential or complete ","code_information":[{"code":"361","type":"RC"},{"code":"64742","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Genome, ultra-rapid sequence analysis ","code_information":[{"code":"0426U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7582.200,"maximum":8947.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7582.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8947.000,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy ","code_information":[{"code":"56640","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Partial laryngectomy (hemilaryngectomy); anterovertical ","code_information":[{"code":"31380","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection, sumatriptan succinate, 6 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) ","drug_information":{"unit":6.000000000000000e+000,"type":"ME"},"code_information":[{"code":"636","type":"RC"},{"code":"901520","type":"CDM"},{"code":"J3030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":407.430,"maximum":407.430,"gross_charge":1399.00,"discounted_cash":1399.00,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":407.430,"methodology":"fee schedule"}]}]},{"description":"Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19») ","code_information":[{"code":"319","type":"RC"},{"code":"86769","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.130,"maximum":49.710,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":42.130,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":49.710,"methodology":"fee schedule"}]}]},{"description":"Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair) ","code_information":[{"code":"54318","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"612","type":"RC"},{"code":"77054","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Uvulectomy, excision of uvula ","code_information":[{"code":"42140","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"146","type":"RC"},{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":61471.950,"maximum":61471.950,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":61471.950,"methodology":"fee schedule"}]}]},{"description":"Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) ","code_information":[{"code":"43510","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial ","code_information":[{"code":"32505","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing ","code_information":[{"code":"615","type":"RC"},{"code":"70555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; complicated (congenital k ","code_information":[{"code":"50405","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dilation of esophagus, over guide wire ","code_information":[{"code":"43453","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection of sinus tract; therapeutic (separate procedure) ","code_information":[{"code":"20500","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/ ","code_information":[{"code":"141","type":"RC"},{"code":"512","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13367.020,"maximum":13367.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13367.020,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (MNS blood group) genotyping (GYPB), gene analysis, GYPB (glycophorin B) introns 1, 5, pseudoexon 3 ","code_information":[{"code":"0190U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) ","code_information":[{"code":"88283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":58.740,"maximum":119.410,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":61.740,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":69.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":61.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":61.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":61.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":61.740,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":72.030,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":70.660,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":69.970,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":72.030,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":119.410,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":69.970,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":102.900,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":72.030,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":72.030,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":66.540,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":82.320,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":69.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":69.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":69.290,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":58.740,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":102.900,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":72.030,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":69.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":69.970,"methodology":"fee schedule"}]}]},{"description":"Excision or unroofing of cyst(s) of kidney ","code_information":[{"code":"362","type":"RC"},{"code":"50280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Embryo transfer, intrauterine ","code_information":[{"code":"499","type":"RC"},{"code":"58974","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe ","code_information":[{"code":"20969","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addi ","code_information":[{"code":"17003","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of tarsometatarsal joint dislocation; without anesthesia ","code_information":[{"code":"28600","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"033","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":13420.480,"maximum":13420.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13420.480,"methodology":"fee schedule"}]}]},{"description":"Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration ","code_information":[{"code":"0539T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5988.600,"maximum":7284.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Pollicization of a digit ","code_information":[{"code":"26550","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16473.030,"maximum":16473.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16473.030,"methodology":"fee schedule"}]}]},{"description":"Cholecystectomy with exploration of common duct; with choledochoenterostomy ","code_information":[{"code":"369","type":"RC"},{"code":"47612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WIT ","code_information":[{"code":"214","type":"RC"},{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":53025.790,"maximum":53025.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":53025.790,"methodology":"fee schedule"}]}]},{"description":"Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification ","code_information":[{"code":"323","type":"RC"},{"code":"78469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":228.080,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":370.180,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":228.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Anatomic model 3D-printed from image data set(s); first individually prepared and processed component of an anatomic structure ","code_information":[{"code":"0559T","type":"CPT"},{"code":"329","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":125.240,"maximum":125.240,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":125.240,"methodology":"fee schedule"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8696.250,"maximum":8696.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8696.250,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; ","code_information":[{"code":"619","type":"RC"},{"code":"75557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian ","code_information":[{"code":"321","type":"RC"},{"code":"75957","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":335.410,"maximum":571.170,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":571.170,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":335.410,"methodology":"fee schedule"}]}]},{"description":"Urography (pyelography), intravenous, with or without KUB, with or without tomography ","code_information":[{"code":"320","type":"RC"},{"code":"74400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.580,"maximum":401.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":185.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":210.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":185.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":225.500,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":163.610,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":149.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, sacroiliac joints; less than 3 views ","code_information":[{"code":"324","type":"RC"},{"code":"72200","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":35.880,"maximum":43.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":43.630,"methodology":"fee schedule"}]}]},{"description":"Extraction (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) ","code_information":[{"code":"10040","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Implantation of anterior segment intraocular nonbiodegradable drug-eluting system, internal approach ","code_information":[{"code":"0660T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Application of long leg cast brace ","code_information":[{"code":"29358","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"120","type":"RC"},{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":44075.610,"maximum":44075.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":44075.610,"methodology":"fee schedule"}]}]},{"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":"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":898.080,"maximum":935.500,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":916.790,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":935.500,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":898.080,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":916.790,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":935.500,"methodology":"fee schedule"}]}]},{"description":"Acetylcholine receptor (AChR); blocking antibody ","code_information":[{"code":"311","type":"RC"},{"code":"86042","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.400,"maximum":21.710,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.710,"methodology":"fee schedule"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; popliteal artery ","code_information":[{"code":"35303","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, cervical; 2 or 3 views ","code_information":[{"code":"322","type":"RC"},{"code":"72040","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":14.080,"maximum":17.120,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.120,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITHOUT CC/MCC ","code_information":[{"code":"159","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":6616.790,"maximum":6616.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6616.790,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EMBOLISM WITHOUT MCC ","code_information":[{"code":"127","type":"RC"},{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7304.720,"maximum":7304.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7304.720,"methodology":"fee schedule"}]}]},{"description":"Rheumatoid factor; quantitative ","code_information":[{"code":"86431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.860,"maximum":9.870,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":5.730,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":5.840,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":9.870,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":8.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":5.500,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":6.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.730,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.730,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":5.730,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":4.860,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":8.500,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":5.780,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6046.490,"maximum":6046.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6046.490,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22139.680,"maximum":22139.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22139.680,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed ","code_information":[{"code":"369","type":"RC"},{"code":"43279","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motionºs» and/or ejection fractionºs», when performed); multiple studies at rest and stress (exercis ","code_information":[{"code":"359","type":"RC"},{"code":"78431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2655.590,"maximum":2655.590,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2655.590,"methodology":"fee schedule"}]}]},{"description":"Infusion or instillation of radioelement solution (includes 3-month follow-up care) ","code_information":[{"code":"342","type":"RC"},{"code":"77750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":310.320,"maximum":310.320,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.320,"methodology":"fee schedule"}]}]},{"description":"Initial open implantation of baroreflex activation therapy (BAT) modulation system, including lead placement onto the carotid sinus, lead tunnelling, connection to a pulse generator placed in a distan ","code_information":[{"code":"360","type":"RC"},{"code":"64654","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":33480.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33480.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thyroid carcinoma metastases imaging; whole body ","code_information":[{"code":"614","type":"RC"},{"code":"78018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75901","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":291.150,"maximum":354.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":291.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":330.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":291.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":354.090,"methodology":"fee schedule"}]}]},{"description":"Biopsy of testis, incisional (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"54505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Repair of nail bed ","code_information":[{"code":"11760","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Delay of flap or sectioning of flap (division and inset); at trunk ","code_information":[{"code":"15600","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Selenium ","code_information":[{"code":"84255","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":23.870,"maximum":30.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":28.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.530,"methodology":"fee schedule"}]}]},{"description":"Venography, adrenal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75840","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":70.940,"maximum":86.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":70.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":80.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":70.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":86.280,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis ","code_information":[{"code":"47800","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Prostate specific antigen (PSA); free ","code_information":[{"code":"300","type":"RC"},{"code":"84154","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.190,"maximum":21.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.230,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.390,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.390,"methodology":"fee schedule"}]}]},{"description":"Fluocinol acet intravit i ","code_information":[{"code":"9450","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":492.210,"maximum":761.150,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":512.510,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":522.660,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":532.810,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":517.580,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":507.440,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":532.810,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":532.810,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":492.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":512.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":512.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":512.510,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":507.440,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":507.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":507.440,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":761.150,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":532.810,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":507.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":517.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":507.440,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":517.580,"methodology":"fee schedule"}]}]},{"description":"Indium in-111 oxyquinoline, diagnostic, per 0.5 millicurie ","code_information":[{"code":"892","type":"RC"},{"code":"A9547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1787.640,"maximum":1787.640,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1787.640,"methodology":"fee schedule"}]}]},{"description":"Electrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arr ","code_information":[{"code":"0930T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, forearm, with brachial artery exploration ","code_information":[{"code":"24495","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"44388","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine ","code_information":[{"code":"0316U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18.660,"maximum":22.020,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.660,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.020,"methodology":"fee schedule"}]}]},{"description":"Vaginectomy, complete removal of vaginal wall; ","code_information":[{"code":"57110","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure) ","code_information":[{"code":"38780","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, larynx ","code_information":[{"code":"31599","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy ","code_information":[{"code":"43865","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal) ","code_information":[{"code":"362","type":"RC"},{"code":"42844","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, elastography; first target lesion ","code_information":[{"code":"340","type":"RC"},{"code":"76982","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplast ","code_information":[{"code":"36907","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY ","code_information":[{"code":"219","type":"RC"},{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8714.070,"maximum":8714.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8714.070,"methodology":"fee schedule"}]}]},{"description":"PERCUT KYPHOPLASTY THOR ","code_information":[{"code":"22523","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":3446.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Evacuation of subungual hematoma ","code_information":[{"code":"11740","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cephalin floculation, blood ","code_information":[{"code":"302","type":"RC"},{"code":"P2028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.630,"maximum":5.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.450,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.950,"methodology":"fee schedule"}]}]},{"description":"Division of scalenus anticus; without resection of cervical rib ","code_information":[{"code":"21700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, elastography; first target lesion ","code_information":[{"code":"351","type":"RC"},{"code":"76982","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and prob ","code_information":[{"code":"0255U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29.550,"maximum":37.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":29.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":34.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":29.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34.760,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":31.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":37.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":31.600,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, implantation or replacement of lower esophageal sphincter neurostimulator electrode array and neurostimulator pulse generator or receiver, requiring pocket creation and connecti ","code_information":[{"code":"1013T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19440.000,"maximum":19440.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"612","type":"RC"},{"code":"72130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance ","code_information":[{"code":"37187","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm ","code_information":[{"code":"11601","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"SURGICAL OPENING ESOPHAGUS ","code_information":[{"code":"43350","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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, single plane body section (eg, tomography), other than with urography ","code_information":[{"code":"610","type":"RC"},{"code":"76100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Gastrotomy; with suture repair of bleeding ulcer ","code_information":[{"code":"43501","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less ","code_information":[{"code":"11600","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy ","code_information":[{"code":"58954","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, head or brain; without contrast material ","code_information":[{"code":"409","type":"RC"},{"code":"70450","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":53.360,"maximum":64.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":53.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":60.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":53.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":64.890,"methodology":"fee schedule"}]}]},{"description":"EPISTAXIS WITH MCC ","code_information":[{"code":"150","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11058.010,"maximum":11058.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11058.010,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique ","code_information":[{"code":"307","type":"RC"},{"code":"87485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.750,"maximum":23.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.050,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal) ","code_information":[{"code":"360","type":"RC"},{"code":"42844","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"RENAL FAILURE WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12123.760,"maximum":12123.760,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12123.760,"methodology":"fee schedule"}]}]},{"description":"INSERT URETERAL TUBE ","code_information":[{"code":"360","type":"RC"},{"code":"50393","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"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":"403","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1833.060,"maximum":1833.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1833.060,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC ","code_information":[{"code":"489","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6605.070,"maximum":7149.810,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":7149.810,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":6605.070,"methodology":"fee schedule"}]}]},{"description":"Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy) ","code_information":[{"code":"29855","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed ","code_information":[{"code":"303","type":"RC"},{"code":"87150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.810,"maximum":41.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage ","code_information":[{"code":"27244","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment ","code_information":[{"code":"22328","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of ","code_information":[{"code":"490","type":"RC"},{"code":"93750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7242.700,"maximum":7242.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7242.700,"methodology":"fee schedule"}]}]},{"description":"Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon ","code_information":[{"code":"26410","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure) ","code_information":[{"code":"33987","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"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":"93923","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":393.460,"maximum":409.850,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":401.650,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":409.850,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":393.460,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":401.650,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":409.850,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6907.640,"maximum":6907.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6907.640,"methodology":"fee schedule"}]}]},{"description":"Vaginectomy, partial removal of vaginal wall; ","code_information":[{"code":"490","type":"RC"},{"code":"57106","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"27328","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar ","code_information":[{"code":"369","type":"RC"},{"code":"63277","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7050.930,"maximum":7050.930,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7050.930,"methodology":"fee schedule"}]}]},{"description":"CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"81184","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Arrest, epiphyseal (epiphysiodesis), open; distal tibia ","code_information":[{"code":"27730","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14695.110,"maximum":14695.110,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14695.110,"methodology":"fee schedule"}]}]},{"description":"Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair ","code_information":[{"code":"55540","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Levetiracetam ","code_information":[{"code":"80177","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12.390,"maximum":15.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.250,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"352","type":"RC"},{"code":"77078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":182.030,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with transurethral resection or incision of ejaculatory ducts ","code_information":[{"code":"52402","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ureteral embolization or occlusion, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code f ","code_information":[{"code":"50705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia ","code_information":[{"code":"28540","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20069.490,"maximum":20069.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20069.490,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of carpal scaphoid (navicular) fracture; without manipulation ","code_information":[{"code":"25622","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"214","type":"RC"},{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8393.990,"maximum":15285.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8393.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14254.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15285.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14745.300,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"151","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27983.840,"maximum":27983.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27983.840,"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"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC ","code_information":[{"code":"673","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19838.570,"maximum":21474.740,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":21474.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":19838.570,"methodology":"fee schedule"}]}]},{"description":"Percutaneous vertebroplasties (bone biopsies included when performed), first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusiv ","code_information":[{"code":"750","type":"RC"},{"code":"C7505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Venography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"615","type":"RC"},{"code":"75822","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1833.060,"maximum":1833.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1833.060,"methodology":"fee schedule"}]}]},{"description":"Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incisionºs») ","code_information":[{"code":"27681","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay ºeg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA»), c ","code_information":[{"code":"303","type":"RC"},{"code":"80307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":58.100,"maximum":73.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":58.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":68.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":58.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":68.350,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":62.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":73.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":62.140,"methodology":"fee schedule"}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"347","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17930.860,"maximum":17930.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17930.860,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure when performed ","code_information":[{"code":"32655","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endosco ","code_information":[{"code":"367","type":"RC"},{"code":"66984","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Babesia microti, amplified probe technique ","code_information":[{"code":"87469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.050,"maximum":52.640,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":32.970,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":32.030,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":47.100,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":34.040,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":30.050,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":31.400,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":52.640,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at ","code_information":[{"code":"481","type":"RC"},{"code":"C7539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13359.890,"maximum":13359.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13359.890,"methodology":"fee schedule"}]}]},{"description":"Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) ","code_information":[{"code":"33202","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9657.000,"maximum":40306.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY ","code_information":[{"code":"101","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11657.540,"maximum":11657.540,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11657.540,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of patellar dislocation; requiring anesthesia ","code_information":[{"code":"27562","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tracheoplasty; cervical ","code_information":[{"code":"31750","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19») vaccine, mRNA-LNP, spike protein, 3 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use ","code_information":[{"code":"636","type":"RC"},{"code":"91318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":140.760,"maximum":140.760,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":140.760,"methodology":"fee schedule"}]}]},{"description":"Release or recession, hamstring, proximal ","code_information":[{"code":"27097","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) ","code_information":[{"code":"49322","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure) ","code_information":[{"code":"33606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) ","code_information":[{"code":"362","type":"RC"},{"code":"57105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, Nikaidoh procedure); without coronary ostium reimplantation ","code_information":[{"code":"33782","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; common carotid-ipsilateral internal carotid ","code_information":[{"code":"35501","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"111","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7765.230,"maximum":7765.230,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7765.230,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older ","code_information":[{"code":"33984","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10022.200,"maximum":10022.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10022.200,"methodology":"fee schedule"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC ","code_information":[{"code":"074","type":"MS-DRG"},{"code":"142","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8914.390,"maximum":8914.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8914.390,"methodology":"fee schedule"}]}]},{"description":"RHEUMATOID, OTHER ARTHRITIS; M > 26.15 & M < 36.35 ","code_information":[{"code":"148","type":"RC"},{"code":"C1302","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19197.940,"maximum":21968.770,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20979.190,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19791.690,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21968.770,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20781.270,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":19197.940,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19989.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19989.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19989.610,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19791.690,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":21968.770,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":21968.770,"methodology":"fee schedule"}]}]},{"description":"CPTR-ASST DIR MS PX IO IMG ","code_information":[{"code":"20986","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"MASTECTOMY FOR MALIGNANCY WITH CC/MCC ","code_information":[{"code":"214","type":"RC"},{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15300.340,"maximum":15300.340,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15300.340,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each ","code_information":[{"code":"28476","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":7967.210,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or cranioplasty ","code_information":[{"code":"62115","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, typing; other methods ","code_information":[{"code":"309","type":"RC"},{"code":"87158","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.240,"maximum":9.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8.510,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.740,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, 1 stage or first stage ","code_information":[{"code":"67971","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALLERGIC REACTIONS WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"915","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13553.790,"maximum":13553.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13553.790,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"143","type":"RC"},{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10923.990,"maximum":10923.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10923.990,"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":737.200,"maximum":1140.000,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":767.600,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":798.000,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":782.800,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":798.000,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":1140.000,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":798.000,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":798.000,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":737.200,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":912.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":767.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":767.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":767.600,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":1140.000,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":798.000,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":775.200,"methodology":"fee schedule"}]}]},{"description":"Partial laryngectomy (hemilaryngectomy); laterovertical ","code_information":[{"code":"31375","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10797.810,"maximum":10797.810,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10797.810,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services ","code_information":[{"code":"321","type":"RC"},{"code":"77399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":156.670,"maximum":156.670,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":156.670,"methodology":"fee schedule"}]}]},{"description":"17-hydroxypregnenolone ","code_information":[{"code":"319","type":"RC"},{"code":"84143","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.810,"maximum":26.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.920,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) ","code_information":[{"code":"25066","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Methotrexate (xatmep), oral, 2.5 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J8612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":48.220,"maximum":48.220,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":48.220,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"322","type":"RC"},{"code":"72191","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":111.570,"maximum":135.690,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":111.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":126.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":111.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":135.690,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, chest (includes mediastinum), real time with image documentation ","code_information":[{"code":"409","type":"RC"},{"code":"76604","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"DIABETES WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5994.450,"maximum":5994.450,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5994.450,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"72159","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":361.030,"maximum":439.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":361.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":409.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":361.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":439.070,"methodology":"fee schedule"}]}]},{"description":"Anoplasty, plastic operation for stricture; infant ","code_information":[{"code":"46705","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope ","code_information":[{"code":"31531","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":9382.710,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":9195.060,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":9382.710,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":9007.400,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":9195.060,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":9382.710,"methodology":"fee schedule"}]}]},{"description":"DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed ","code_information":[{"code":"81161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179.010,"maximum":418.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":251.100,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":281.790,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":251.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":251.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":251.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":251.100,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":187.960,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":287.370,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":182.590,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":292.950,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":393.390,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":284.580,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":268.510,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":279.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":292.950,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":292.950,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":270.630,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":334.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":281.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":281.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":281.790,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":279.000,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":279.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":279.000,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":179.010,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":418.500,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":292.950,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":279.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":284.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":279.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":284.580,"methodology":"fee schedule"}]}]},{"description":"Laryngectomy; subtotal supraglottic, without radical neck dissection ","code_information":[{"code":"31367","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT ","code_information":[{"code":"008","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":41519.950,"maximum":41519.950,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":41519.950,"methodology":"fee schedule"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13450.430,"maximum":13450.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13450.430,"methodology":"fee schedule"}]}]},{"description":"Percutaneous electrical nerve field stimulation, cranial nerves, without implantation ","code_information":[{"code":"369","type":"RC"},{"code":"64567","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of ulnar shaft fracture; without manipulation ","code_information":[{"code":"25530","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rhinoplasty, primary; including major septal repair ","code_information":[{"code":"30420","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of benign tumor or cyst of mandible, by enucleation and/or curettage ","code_information":[{"code":"21040","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Liver imaging; with vascular flow ","code_information":[{"code":"329","type":"RC"},{"code":"78202","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":353.140,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":353.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED ","code_information":[{"code":"49561","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision ","code_information":[{"code":"303","type":"RC"},{"code":"88174","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.370,"maximum":29.940,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":29.940,"methodology":"fee schedule"}]}]},{"description":"Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication ","code_information":[{"code":"57308","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC ","code_information":[{"code":"214","type":"RC"},{"code":"745","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9675.030,"maximum":9675.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9675.030,"methodology":"fee schedule"}]}]},{"description":"Transcatheter biopsy, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75970","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":49.490,"maximum":60.190,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":49.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":49.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":60.190,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation ","code_information":[{"code":"28576","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":14021.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Catheterization, umbilical artery, newborn, for diagnosis or therapy ","code_information":[{"code":"36660","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES ","code_information":[{"code":"111","type":"RC"},{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":25380.420,"maximum":25380.420,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":25380.420,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 34 ","code_information":[{"code":"01534","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":7272.630,"maximum":7272.630,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":7272.630,"methodology":"fee schedule"}]}]},{"description":"Reduction forehead; contouring only ","code_information":[{"code":"21137","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"SIGMOIDOSCOPY W/ABLATE TUMR ","code_information":[{"code":"45339","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1488.000,"maximum":1898.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint ","code_information":[{"code":"28024","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC ","code_information":[{"code":"144","type":"RC"},{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20528.580,"maximum":20528.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20528.580,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, cleft foot ","code_information":[{"code":"28360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":14021.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"44388","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15235.480,"maximum":15235.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15235.480,"methodology":"fee schedule"}]}]},{"description":"DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles ","code_information":[{"code":"309","type":"RC"},{"code":"81234","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; metatarsal ","code_information":[{"code":"28173","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach ","code_information":[{"code":"33362","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) ","code_information":[{"code":"26852","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete repair of anomalous pulmonary venous return (supracardiac, intracardiac, or infracardiac types) ","code_information":[{"code":"33730","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious disease (Bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qua ","code_information":[{"code":"0223U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":491.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":491.800,"methodology":"fee schedule"}]}]},{"description":"Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch ","code_information":[{"code":"361","type":"RC"},{"code":"69610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) ","code_information":[{"code":"302","type":"RC"},{"code":"81224","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":157.780,"maximum":199.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":157.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":185.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":157.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":185.630,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":199.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":168.750,"methodology":"fee schedule"}]}]},{"description":"Biopsy, muscle, percutaneous needle ","code_information":[{"code":"20206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4087.600,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4005.850,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":4087.600,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":3924.100,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":4005.850,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":4087.600,"methodology":"fee schedule"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm ","code_information":[{"code":"11406","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":87238.880,"maximum":87238.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":87238.880,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the ","code_information":[{"code":"37248","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography ","code_information":[{"code":"321","type":"RC"},{"code":"78635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":340.860,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":617.630,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":340.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) ","code_information":[{"code":"31090","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Injection fitusiran 0.04 ","code_information":[{"code":"889","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":128.640,"maximum":198.930,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":133.950,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":136.600,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":139.250,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":135.270,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":132.620,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":139.250,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":139.250,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":128.640,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":133.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":133.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":133.950,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":132.620,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":132.620,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":132.620,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":198.930,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":139.250,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":132.620,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":135.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":132.620,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":135.270,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17831.060,"maximum":17831.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17831.060,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":33381.030,"maximum":33381.030,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":33381.030,"methodology":"fee schedule"}]}]},{"description":"RENAL FAILURE WITHOUT CC/MCC ","code_information":[{"code":"206","type":"RC"},{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5845.460,"maximum":5845.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5845.460,"methodology":"fee schedule"}]}]},{"description":"Repair, congenital arteriovenous fistula; thorax and abdomen ","code_information":[{"code":"35182","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"AICD LEAD PROCEDURES ","code_information":[{"code":"172","type":"RC"},{"code":"265","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27359.370,"maximum":27359.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27359.370,"methodology":"fee schedule"}]}]},{"description":"Necropsy (autopsy), gross and microscopic; without CNS ","code_information":[{"code":"312","type":"RC"},{"code":"88020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":308.160,"maximum":362.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":308.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":362.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":308.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":362.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":362.540,"methodology":"fee schedule"}]}]},{"description":"Fetal non-stress test ","code_information":[{"code":"59025","type":"CPT"},{"code":"813358","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":505.880,"maximum":526.960,"gross_charge":916.00,"discounted_cash":916.00,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":516.420,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":526.960,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":505.880,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":516.420,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":526.960,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH CC ","code_information":[{"code":"038","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":13133.190,"maximum":13133.190,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13133.190,"methodology":"fee schedule"}]}]},{"description":"Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length ","code_information":[{"code":"369","type":"RC"},{"code":"64891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"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":"87400","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13.210,"maximum":16.670,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.130,"methodology":"fee schedule"}]}]},{"description":"Excision of sublingual gland ","code_information":[{"code":"42450","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH CC ","code_information":[{"code":"172","type":"RC"},{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9527.470,"maximum":9527.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9527.470,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification ","code_information":[{"code":"302","type":"RC"},{"code":"87512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.050,"maximum":49.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":39.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":45.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":39.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":49.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":41.760,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"137","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24092.970,"maximum":24092.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24092.970,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, upper extremity, with or without contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"73225","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":105.580,"maximum":128.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":105.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":119.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":105.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":128.410,"methodology":"fee schedule"}]}]},{"description":"Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix ","code_information":[{"code":"499","type":"RC"},{"code":"57421","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Subconjunctival injection ","code_information":[{"code":"367","type":"RC"},{"code":"68200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"219","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10988.870,"maximum":10988.870,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10988.870,"methodology":"fee schedule"}]}]},{"description":"Kidney imaging morphology; with vascular flow ","code_information":[{"code":"320","type":"RC"},{"code":"78701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":229.120,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":382.450,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":229.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos ","code_information":[{"code":"89290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":182.140,"maximum":448.880,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":182.140,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":448.880,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":430.920,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":448.880,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; urine ","code_information":[{"code":"83069","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.390,"maximum":6.880,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3.560,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":3.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":3.560,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":4.150,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":4.070,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":4.030,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":4.150,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":6.880,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":4.030,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":5.930,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":4.150,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":4.150,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":3.830,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":3.990,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":3.990,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":3.990,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":3.390,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":5.930,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":4.150,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":3.950,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":4.030,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL ","code_information":[{"code":"111","type":"RC"},{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":49197.640,"maximum":49197.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":49197.640,"methodology":"fee schedule"}]}]},{"description":"Elevation of depressed skull fracture; simple, extradural ","code_information":[{"code":"62000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8361.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":8361.000,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS ","code_information":[{"code":"143","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":47437.540,"maximum":47437.540,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":47437.540,"methodology":"fee schedule"}]}]},{"description":"Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups, without imaging guidance ","code_information":[{"code":"369","type":"RC"},{"code":"46946","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy ","code_information":[{"code":"362","type":"RC"},{"code":"55875","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19645.320,"maximum":19645.320,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19645.320,"methodology":"fee schedule"}]}]},{"description":"Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection ","code_information":[{"code":"490","type":"RC"},{"code":"51050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil ","code_information":[{"code":"0978T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7284.450,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"}]}]},{"description":"Secondary revision of orbitocraniofacial reconstruction ","code_information":[{"code":"21275","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Percutaneous arteriovenous fistula creation (avf), direct, any site, using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular ","code_information":[{"code":"481","type":"RC"},{"code":"G2171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"}]}]},{"description":"Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graf ","code_information":[{"code":"26125","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging repo ","code_information":[{"code":"341","type":"RC"},{"code":"76014","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.900,"maximum":28.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":28.900,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Amino acids; single, qualitative, each specimen ","code_information":[{"code":"304","type":"RC"},{"code":"82127","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.260,"maximum":16.730,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.180,"methodology":"fee schedule"}]}]},{"description":"Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus ","code_information":[{"code":"369","type":"RC"},{"code":"51065","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Ligamentous reconstruction (augmentation), knee; intra-articular (open) ","code_information":[{"code":"27428","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, forearm, with brachial artery exploration ","code_information":[{"code":"24495","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"148","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7248.400,"maximum":7248.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7248.400,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9300.060,"maximum":9300.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9300.060,"methodology":"fee schedule"}]}]},{"description":"Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck ","code_information":[{"code":"51715","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"160","type":"RC"},{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":56302.880,"maximum":56302.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":56302.880,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, lumbar spine; with contrast material ","code_information":[{"code":"400","type":"RC"},{"code":"72132","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":159.440,"maximum":193.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":159.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":180.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":159.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":193.900,"methodology":"fee schedule"}]}]},{"description":"Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch ","code_information":[{"code":"69610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8009.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":8009.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":8009.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":8009.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":8009.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5721.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":3740.260,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":3816.590,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":3663.930,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":3740.260,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":3816.590,"methodology":"fee schedule"}]}]},{"description":"Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J9230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":281.500,"maximum":281.500,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":281.500,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, cervical spine; with contrast material ","code_information":[{"code":"401","type":"RC"},{"code":"72126","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"024","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":29453.090,"maximum":29453.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":29453.090,"methodology":"fee schedule"}]}]},{"description":"PROSTATECTOMY WITH CC ","code_information":[{"code":"206","type":"RC"},{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14036.410,"maximum":14036.410,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14036.410,"methodology":"fee schedule"}]}]},{"description":"Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) ","code_information":[{"code":"341","type":"RC"},{"code":"77600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":310.320,"maximum":310.320,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.320,"methodology":"fee schedule"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC ","code_information":[{"code":"032","type":"MS-DRG"},{"code":"212","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":16757.460,"maximum":16757.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16757.460,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (colton blood group) genotyping (CO), gene analysis, AQP1 (aquaporin 1) exon 1 ","code_information":[{"code":"0181U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":173.160,"maximum":218.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":218.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"174","type":"RC"},{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26938.770,"maximum":26938.770,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26938.770,"methodology":"fee schedule"}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT ","code_information":[{"code":"164","type":"RC"},{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15316.730,"maximum":15316.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15316.730,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) ","code_information":[{"code":"27357","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CSTB (cystatin B), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, Short Tandem Requests (STR) expansions, mobile element insertions, and ","code_information":[{"code":"0232U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) ","code_information":[{"code":"66625","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) ","code_information":[{"code":"43245","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"GUILLIAN BARRE; M > 18.05 & M < 35.95 ","code_information":[{"code":"024","type":"RC"},{"code":"D1902","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19314.630,"maximum":19314.630,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19314.630,"methodology":"fee schedule"}]}]},{"description":"Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children ","code_information":[{"code":"15273","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm ","code_information":[{"code":"12045","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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; 12.6 cm to 20.0 cm ","code_information":[{"code":"12055","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) ","code_information":[{"code":"480","type":"RC"},{"code":"64575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":39805.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37122.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39805.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":38400.000,"methodology":"case rate"}]}]},{"description":"INJECTION FOR LIVER X-RAYS ","code_information":[{"code":"47505","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Obstetrics (preeclampsia), biochemical assay of placental-growth factor, time-resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia ","code_information":[{"code":"0243U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":60.220,"maximum":76.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":60.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":70.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":60.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":70.850,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":76.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":64.410,"methodology":"fee schedule"}]}]},{"description":"Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection ","code_information":[{"code":"360","type":"RC"},{"code":"38555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"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":"0796T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral ","code_information":[{"code":"32607","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm ","code_information":[{"code":"21930","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC ","code_information":[{"code":"174","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19869.880,"maximum":19869.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19869.880,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, esophagus ","code_information":[{"code":"43289","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS ","code_information":[{"code":"120","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":50838.680,"maximum":50838.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":50838.680,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22382.060,"maximum":22382.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22382.060,"methodology":"fee schedule"}]}]},{"description":"Omeza collagen matrix, per 100 mg ","code_information":[{"code":"344","type":"RC"},{"code":"A2014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":330.560,"maximum":330.560,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":330.560,"methodology":"fee schedule"}]}]},{"description":"DIABETES WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7954.860,"maximum":7954.860,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7954.860,"methodology":"fee schedule"}]}]},{"description":"Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic ","code_information":[{"code":"47711","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis ","code_information":[{"code":"303","type":"RC"},{"code":"81425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4704.170,"maximum":5936.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4704.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5534.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4704.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5534.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5031.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5936.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5031.200,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands ","code_information":[{"code":"52214","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or ","code_information":[{"code":"499","type":"RC"},{"code":"61889","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":26570.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Azithromycin dihydrate, oral, capsules/powder, 1 gram ","code_information":[{"code":"892","type":"RC"},{"code":"Q0144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":28.010,"maximum":28.010,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28.010,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, neck; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"70548","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":93.220,"maximum":113.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":93.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":105.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":93.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":113.380,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9300.060,"maximum":9300.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9300.060,"methodology":"fee schedule"}]}]},{"description":"OSTEOARTHRITIS; M > 37.65 ","code_information":[{"code":"128","type":"RC"},{"code":"C1201","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":16437.060,"maximum":18809.420,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":17962.150,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":16945.420,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":18809.420,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17792.700,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":16437.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17114.880,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":17114.880,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":17114.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":16945.420,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":18809.420,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":18809.420,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with esophagomyotomy (Heller type) ","code_information":[{"code":"32665","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone marrow imaging; limited area ","code_information":[{"code":"341","type":"RC"},{"code":"78102","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":33.440,"maximum":38.550,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":33.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":33.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.550,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0D1A47B","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED IMAGES, WITH KUB ","code_information":[{"code":"322","type":"RC"},{"code":"74241","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":158.840,"maximum":158.840,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":158.840,"methodology":"fee schedule"}]}]},{"description":"Oncology (solid tumor), DNA (80 genes) & RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions, deletions, copy number alterations, microsatellite ","code_information":[{"code":"0409U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2919.600,"maximum":3445.130,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3445.130,"methodology":"fee schedule"}]}]},{"description":"Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) ","code_information":[{"code":"361","type":"RC"},{"code":"58120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Albumin; ischemia modified ","code_information":[{"code":"302","type":"RC"},{"code":"82045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.730,"maximum":40.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":31.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":31.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37.330,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":33.940,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":40.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33.940,"methodology":"fee schedule"}]}]},{"description":"Oncology (solid tumor), tumor cell culture in 3D microenvironment, 36 or more drug panel, reported as tumor-response prediction for each drug ","code_information":[{"code":"0511U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2836.660,"maximum":3579.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2836.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3337.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2836.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3337.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3579.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3033.860,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable moni ","code_information":[{"code":"0527T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs ","code_information":[{"code":"21811","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC ","code_information":[{"code":"211","type":"RC"},{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16255.600,"maximum":16255.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16255.600,"methodology":"fee schedule"}]}]},{"description":"Fetal contraction stress test ","code_information":[{"code":"360","type":"RC"},{"code":"59020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application ","code_information":[{"code":"41019","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection of air or contrast into peritoneal cavity (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"49400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Sodium; serum, plasma or whole blood ","code_information":[{"code":"314","type":"RC"},{"code":"84295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.810,"maximum":5.680,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.680,"methodology":"fee schedule"}]}]},{"description":"Bone marrow harvesting for transplantation; autologous ","code_information":[{"code":"38232","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Excision of coarctation of aorta, with or without associated patent ductus arteriosus; repair using either left subclavian artery or prosthetic material as gusset for enlargement ","code_information":[{"code":"33851","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC Pediatric","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11229.930,"maximum":15721.470,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":15721.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":15721.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":15721.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":15721.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":11229.930,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor VIII, VW factor, ristocetin cofactor ","code_information":[{"code":"309","type":"RC"},{"code":"85245","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.450,"maximum":27.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.940,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine; thoracolumbar junction, minimum of 2 views ","code_information":[{"code":"352","type":"RC"},{"code":"72080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Real-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance (List separately in addition to code for primary procedure) ","code_information":[{"code":"0443T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Esophagoplasty (plastic repair or reconstruction), thoracic approach; with repair of tracheoesophageal fistula ","code_information":[{"code":"43312","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"084","type":"MS-DRG"},{"code":"127","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8379.730,"maximum":8379.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8379.730,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique ","code_information":[{"code":"87485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.170,"maximum":34.910,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":18.050,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":20.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":18.050,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":18.050,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":18.050,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":18.050,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":20.650,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":34.910,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":30.080,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":19.450,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":24.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20.250,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":17.170,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":30.080,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":20.450,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"201","type":"RC"},{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8894.430,"maximum":8894.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8894.430,"methodology":"fee schedule"}]}]},{"description":"Riboflavin (Vitamin B-2) ","code_information":[{"code":"301","type":"RC"},{"code":"84252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.920,"maximum":23.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.240,"methodology":"fee schedule"}]}]},{"description":"Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion ","code_information":[{"code":"69745","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent ","code_information":[{"code":"362","type":"RC"},{"code":"68815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH ","code_information":[{"code":"157","type":"RC"},{"code":"617","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14898.990,"maximum":14898.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14898.990,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplast ","code_information":[{"code":"36907","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4635.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4635.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull ","code_information":[{"code":"61518","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closure of rectovesical fistula; ","code_information":[{"code":"45800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HAND PROCEDURES FOR INJURIES ","code_information":[{"code":"122","type":"RC"},{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15569.100,"maximum":15569.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15569.100,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of distal radioulnar dislocation with manipulation ","code_information":[{"code":"25675","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"206","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14466.990,"maximum":14466.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14466.990,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC ","code_information":[{"code":"013","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":22109.750,"maximum":22109.750,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22109.750,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6941.150,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6941.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) ","code_information":[{"code":"13122","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Phosphatase, alkaline; ","code_information":[{"code":"301","type":"RC"},{"code":"814272","type":"CDM"},{"code":"84075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.840,"maximum":6.110,"gross_charge":625.25,"discounted_cash":625.25,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.180,"methodology":"fee schedule"}]}]},{"description":"Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication) ","code_information":[{"code":"499","type":"RC"},{"code":"57220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Drainage of extraperitoneal lymphocele to peritoneal cavity, open ","code_information":[{"code":"49062","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC ","code_information":[{"code":"172","type":"RC"},{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20367.470,"maximum":20367.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20367.470,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12491.610,"maximum":12491.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12491.610,"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":"0339T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"151","type":"RC"},{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18833.360,"maximum":18833.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18833.360,"methodology":"fee schedule"}]}]},{"description":"GUILLIAN BARRE; M > 18.05 & M < 35.95 ","code_information":[{"code":"138","type":"RC"},{"code":"D1902","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":18735.190,"maximum":21439.230,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20473.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19314.630,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21439.230,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20280.360,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":18735.190,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19507.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19507.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19507.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19314.630,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":21439.230,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":21439.230,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with direct vision internal urethrotomy ","code_information":[{"code":"52276","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Injection, pralatrexate, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J9307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":844.350,"maximum":844.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":844.350,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of clavicular fracture; with manipulation ","code_information":[{"code":"23505","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Red cell antigen (H blood group) genotyping (FUT2), gene analysis, FUT2 (fycosyltransferase 2) exon 2 ","code_information":[{"code":"0186U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":173.160,"maximum":218.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":173.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":203.720,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":218.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Valvuloplasty, mitral valve, with cardiopulmonary bypass; ","code_information":[{"code":"33425","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12724.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"PERIPH FIELD STIMUL PERM ","code_information":[{"code":"0283T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3162.000,"maximum":13614.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13614.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":4135.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3435.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":4096.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Platelets leukocytes redu ","code_information":[{"code":"09526","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":139.930,"maximum":139.930,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":139.930,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"324","type":"RC"},{"code":"73720","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":334.150,"maximum":406.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":334.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":379.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":334.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":406.380,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"042","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":13882.430,"maximum":13882.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13882.430,"methodology":"fee schedule"}]}]},{"description":"Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision ","code_information":[{"code":"88147","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":59.660,"maximum":59.660,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":59.660,"methodology":"fee schedule"}]}]},{"description":"Orchiectomy, radical, for tumor; with abdominal exploration ","code_information":[{"code":"367","type":"RC"},{"code":"54535","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"173","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5293.690,"maximum":5293.690,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5293.690,"methodology":"fee schedule"}]}]},{"description":"Cesarean delivery only; ","code_information":[{"code":"361","type":"RC"},{"code":"59514","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Destruction by neurolytic agent; plantar common digital nerve ","code_information":[{"code":"64632","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Catecholamines; total urine ","code_information":[{"code":"307","type":"RC"},{"code":"82382","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.530,"maximum":32.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":32.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.300,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, open, elbow to shoulder, each tendon ","code_information":[{"code":"24310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7967.210,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"}]}]},{"description":"TREATMENT OF RIB FRACTURE(S) ","code_information":[{"code":"21810","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1488.000,"maximum":1898.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity ","code_information":[{"code":"49323","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14369.190,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5690.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":7390.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9852.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2984.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13794.420,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"}]}]},{"description":"Excision of ganglion, wrist (dorsal or volar); recurrent ","code_information":[{"code":"25112","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, vibration) elastography ","code_information":[{"code":"409","type":"RC"},{"code":"76391","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":276.550,"maximum":336.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":276.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":313.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":276.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":336.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system ","code_information":[{"code":"33237","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":40306.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other ","code_information":[{"code":"E1028","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":21.080,"maximum":32.590,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":21.950,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":22.380,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":22.820,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":22.160,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":21.730,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":22.820,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":22.820,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":21.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":21.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":21.950,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":21.730,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":21.730,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":21.730,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":21.080,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":32.590,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22.820,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":21.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":21.730,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":22.160,"methodology":"fee schedule"}]}]},{"description":"Vascular embolization or occlusion procedure with use of a pressure-generating catheter (e.g., one-way valve, intermittently occluding), inclusive of all radiological supervision and interpretation, i ","code_information":[{"code":"481","type":"RC"},{"code":"C9797","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":26570.300,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps ","code_information":[{"code":"43250","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative ","code_information":[{"code":"0035U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":505.830,"maximum":638.370,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":505.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":595.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":505.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":595.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":638.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":540.990,"methodology":"fee schedule"}]}]},{"description":"Chemical cauterization of granulation tissue (ie, proud flesh) ","code_information":[{"code":"17250","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, palate, uvula ","code_information":[{"code":"42299","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft ","code_information":[{"code":"24342","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WIT ","code_information":[{"code":"143","type":"RC"},{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":53025.790,"maximum":53025.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":53025.790,"methodology":"fee schedule"}]}]},{"description":"Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) ","code_information":[{"code":"20700","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M Pediatric","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20974.260,"maximum":29363.170,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":29363.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":29363.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":29363.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":29363.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":20974.260,"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":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":100309.470,"maximum":100309.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":100309.470,"methodology":"fee schedule"}]}]},{"description":"Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method ","code_information":[{"code":"28292","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg ","code_information":[{"code":"J0703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.890,"maximum":8.970,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":6.520,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":6.100,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":8.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":4.890,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":5.980,"methodology":"fee schedule"}]}]},{"description":"Antibody; Chlamydia ","code_information":[{"code":"312","type":"RC"},{"code":"86631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.820,"maximum":13.950,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.820,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.950,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, limited or localized follow-up study ","code_information":[{"code":"351","type":"RC"},{"code":"76380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":182.030,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26963.000,"maximum":26963.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26963.000,"methodology":"fee schedule"}]}]},{"description":"Venography, renal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"352","type":"RC"},{"code":"75831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10615.310,"maximum":10615.310,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10615.310,"methodology":"fee schedule"}]}]},{"description":"Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed ","code_information":[{"code":"361","type":"RC"},{"code":"44157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Urethrocystography, retrograde, radiological supervision and interpretation ","code_information":[{"code":"614","type":"RC"},{"code":"74450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":285.230,"maximum":285.230,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":285.230,"methodology":"fee schedule"}]}]},{"description":"Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"49010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of laceration; conjunctiva, by mobilization and rearrangement, without hospitalization ","code_information":[{"code":"65272","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"167","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6142.730,"maximum":6142.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6142.730,"methodology":"fee schedule"}]}]},{"description":"Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery ","code_information":[{"code":"54056","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I ","code_information":[{"code":"21159","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision or removal of intracranial neurostimulator electrodes ","code_information":[{"code":"360","type":"RC"},{"code":"61880","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Adrenal imaging, cortex and/or medulla ","code_information":[{"code":"341","type":"RC"},{"code":"78075","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":500.440,"maximum":576.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":500.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":567.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":500.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":576.900,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; transection of vagus nerves, selective or highly selective ","code_information":[{"code":"367","type":"RC"},{"code":"43652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) ","code_information":[{"code":"45303","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Bilirubin, total, transcutaneous ","code_information":[{"code":"309","type":"RC"},{"code":"88720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.690,"maximum":5.920,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.520,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.020,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.020,"methodology":"fee schedule"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC ","code_information":[{"code":"219","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8696.250,"maximum":8696.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8696.250,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12140.880,"maximum":12140.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12140.880,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC SPINAL CORD INJURY; M < 16.05 & A < 63.5 ","code_information":[{"code":"148","type":"RC"},{"code":"D0405","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":31306.080,"maximum":35824.490,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":34210.770,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":32274.310,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":35824.490,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":33888.030,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":31306.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":32597.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":32597.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":32597.060,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":32274.310,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":35824.490,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":35824.490,"methodology":"fee schedule"}]}]},{"description":"Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgM ","code_information":[{"code":"0043U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13.890,"maximum":17.530,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.350,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.860,"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":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"301","type":"RC"},{"code":"81188","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) ","code_information":[{"code":"23532","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transection or avulsion of other cranial nerve, extradural ","code_information":[{"code":"367","type":"RC"},{"code":"64771","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release ","code_information":[{"code":"23130","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC One Day Stay","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) ","code_information":[{"code":"320","type":"RC"},{"code":"G0130","type":"HCPCS"}],"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":40.630,"maximum":49.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":40.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":46.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":40.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.410,"methodology":"fee schedule"}]}]},{"description":"Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) ","code_information":[{"code":"64876","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"211","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6372.270,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6372.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Rectal sensation, tone, and compliance study (eg, barostat) ","code_information":[{"code":"499","type":"RC"},{"code":"91124","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":1637.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3811.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3811.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC ","code_information":[{"code":"987","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18593.720,"maximum":20127.220,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":20127.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":18593.720,"methodology":"fee schedule"}]}]},{"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":"480","type":"RC"},{"code":"93459","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7557.000,"maximum":10077.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7786.250,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8832.650,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7786.250,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8977.370,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":10077.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":7557.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":10077.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10077.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":9136.640,"methodology":"case rate"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7417.150,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection ","code_information":[{"code":"43254","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of laceration; application of tissue glue, wounds of cornea and/or sclera ","code_information":[{"code":"362","type":"RC"},{"code":"65286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; giardia ","code_information":[{"code":"312","type":"RC"},{"code":"87269","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.610,"maximum":16.060,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.060,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheter ","code_information":[{"code":"37263","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence ","code_information":[{"code":"304","type":"RC"},{"code":"81189","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs by quantitative reverse transcription polymerase chain reaction, urine, reported as no molecular evidence, low-, moderate- or ele ","code_information":[{"code":"0424U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":710.600,"maximum":896.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"091","type":"MS-DRG"},{"code":"204","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":14085.600,"maximum":14085.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14085.600,"methodology":"fee schedule"}]}]},{"description":"Revision or removal of gastric neurostimulator electrodes, antrum, open ","code_information":[{"code":"43882","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"77054","type":"CPT"},{"code":"826352","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":94.580,"maximum":94.580,"gross_charge":4956.50,"discounted_cash":4956.50,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":94.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":94.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":94.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":94.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":94.580,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique ","code_information":[{"code":"87496","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.600,"maximum":61.100,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":28.980,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":28.150,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":61.100,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":41.400,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":34.040,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":30.050,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":27.600,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":52.640,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage, thoracic ","code_information":[{"code":"369","type":"RC"},{"code":"63197","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, metacarpal ","code_information":[{"code":"26250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7967.210,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7967.210,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views ","code_information":[{"code":"614","type":"RC"},{"code":"71111","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Injection, anesthetic agent; superior hypogastric plexus ","code_information":[{"code":"360","type":"RC"},{"code":"64517","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound bone density measurement and interpretation, peripheral site(s), any method ","code_information":[{"code":"409","type":"RC"},{"code":"76977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"ACUTE LEUKEMIA WITH OTHER PROCEDURES ","code_information":[{"code":"152","type":"RC"},{"code":"850","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":63297.620,"maximum":63297.620,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":63297.620,"methodology":"fee schedule"}]}]},{"description":"TREATMENT OF RIB FRACTURE ","code_information":[{"code":"21800","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":1496.000,"payers_information":[{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Free jejunum transfer with microvascular anastomosis ","code_information":[{"code":"43496","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC ","code_information":[{"code":"198","type":"MS-DRG"},{"code":"213","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":6671.680,"maximum":6671.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6671.680,"methodology":"fee schedule"}]}]},{"description":"ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"306","type":"RC"},{"code":"81183","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.090,"maximum":161.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical quantification measurement(s) single area (List separately in addition to code for primary procedure) ","code_information":[{"code":"340","type":"RC"},{"code":"78835","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":126.020,"maximum":145.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":126.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":142.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":126.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":145.280,"methodology":"fee schedule"}]}]},{"description":"Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure) ","code_information":[{"code":"329","type":"RC"},{"code":"78020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":113.180,"maximum":113.180,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":113.180,"methodology":"fee schedule"}]}]},{"description":"Dilation of vagina under anesthesia (other than local) ","code_information":[{"code":"57400","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass ","code_information":[{"code":"32853","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":26570.300,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Real-time pressure-sensing epidural guidance system (List separately in addition to code for primary procedure) ","code_information":[{"code":"0777T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"854","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15810.050,"maximum":15810.050,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15810.050,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"130","type":"RC"},{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":39582.350,"maximum":39582.350,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":39582.350,"methodology":"fee schedule"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC ","code_information":[{"code":"067","type":"MS-DRG"},{"code":"142","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":12036.070,"maximum":12036.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12036.070,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe techn ","code_information":[{"code":"307","type":"RC"},{"code":"87503","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.320,"maximum":34.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32.140,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":29.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":34.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.220,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14645.920,"maximum":14645.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14645.920,"methodology":"fee schedule"}]}]},{"description":"Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm ","code_information":[{"code":"36002","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis ","code_information":[{"code":"43334","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace ","code_information":[{"code":"367","type":"RC"},{"code":"63077","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode ","code_information":[{"code":"33215","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":40306.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention ","code_information":[{"code":"322","type":"RC"},{"code":"78707","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":239.380,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":374.270,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":239.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, adductor of hip, open ","code_information":[{"code":"27001","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes ","code_information":[{"code":"367","type":"RC"},{"code":"51575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all man ","code_information":[{"code":"369","type":"RC"},{"code":"37268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC ","code_information":[{"code":"150","type":"RC"},{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13359.890,"maximum":13359.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13359.890,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SIGNS AND SYMPTOMS ","code_information":[{"code":"100","type":"RC"},{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7321.830,"maximum":7321.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7321.830,"methodology":"fee schedule"}]}]},{"description":"Injection, amisulpride, 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J0184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":20.600,"maximum":20.600,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.600,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hand; 2 views ","code_information":[{"code":"329","type":"RC"},{"code":"73120","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":33.040,"maximum":40.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":33.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":33.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":40.180,"methodology":"fee schedule"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA ","code_information":[{"code":"137","type":"RC"},{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":71305.370,"maximum":71305.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":71305.370,"methodology":"fee schedule"}]}]},{"description":"Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit ","code_information":[{"code":"349","type":"RC"},{"code":"78265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":848.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":489.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":555.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":489.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":564.460,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22149.660,"maximum":22149.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22149.660,"methodology":"fee schedule"}]}]},{"description":"Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1) ","code_information":[{"code":"312","type":"RC"},{"code":"83006","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":75.600,"maximum":89.210,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":75.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":89.210,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor, proximal or middle phalanx of finger ","code_information":[{"code":"26260","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITHOUT MCC One Day Stay","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9769.540,"maximum":11883.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11082.500,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9769.540,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11883.600,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Anoplasty, plastic operation for stricture; adult ","code_information":[{"code":"46700","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Injection, dicyclomine hcl, up to 20 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J0500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":24.360,"maximum":24.360,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.360,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint ","code_information":[{"code":"21345","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"206","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8873.040,"maximum":8873.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8873.040,"methodology":"fee schedule"}]}]},{"description":"RENAL FAILURE WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"683","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7809.430,"maximum":7809.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7809.430,"methodology":"fee schedule"}]}]},{"description":"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA ","code_information":[{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4635.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4635.000,"methodology":"per diem","additional_payer_notes":"Days 9+. "}]}]},{"description":"Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract format ","code_information":[{"code":"362","type":"RC"},{"code":"37182","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach ","code_information":[{"code":"45190","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13205.200,"maximum":13205.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13205.200,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/ ","code_information":[{"code":"022","type":"MS-DRG"},{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":24217.010,"maximum":24217.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24217.010,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28935.530,"maximum":28935.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28935.530,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (vaginal infection), identification of 32 pathogenic organisms, swab, real-time PCR, reported as positive or negative for each organism ","code_information":[{"code":"0505U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":635.580,"maximum":802.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":635.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":747.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":635.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":747.750,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":679.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":802.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":679.770,"methodology":"fee schedule"}]}]},{"description":"Patient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathol ","code_information":[{"code":"0794T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":1637.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Calcitonin ","code_information":[{"code":"307","type":"RC"},{"code":"82308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.050,"maximum":31.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29.470,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":26.790,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":31.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26.790,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC ","code_information":[{"code":"212","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17098.220,"maximum":17098.220,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17098.220,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH CC ","code_information":[{"code":"137","type":"RC"},{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9290.080,"maximum":9290.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9290.080,"methodology":"fee schedule"}]}]},{"description":"ANTEPARTUM WITHOUT O.R. PROCEDURE ","code_information":[{"code":"5664","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9535.200,"maximum":14302.800,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":9535.200,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":9725.900,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":14302.800,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":9535.200,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":9535.200,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":9535.200,"methodology":"fee schedule"}]}]},{"description":"Injection, sargramostim (gm-csf), 50 mcg ","code_information":[{"code":"343","type":"RC"},{"code":"J2820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":132.760,"maximum":132.760,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":132.760,"methodology":"fee schedule"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21521.610,"maximum":21521.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":21521.610,"methodology":"fee schedule"}]}]},{"description":"Cinacalcet, oral, 1 mg, (for esrd on dialysis) ","code_information":[{"code":"343","type":"RC"},{"code":"J0604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.130,"maximum":2.130,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.130,"methodology":"fee schedule"}]}]},{"description":"Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition ","code_information":[{"code":"33258","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14006.470,"maximum":14006.470,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14006.470,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH ","code_information":[{"code":"202","type":"RC"},{"code":"616","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26426.920,"maximum":26426.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26426.920,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC SPINAL CORD INJURY; M > 16.05 & M < 30.3 ","code_information":[{"code":"D0403","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":24617.700,"maximum":25648.670,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":25145.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24617.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":25145.760,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":25648.670,"methodology":"fee schedule"}]}]},{"description":"Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised ","code_information":[{"code":"97164","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":54.420,"maximum":84.150,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":56.660,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":57.780,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":58.910,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":57.220,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":56.100,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":58.910,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":58.910,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":54.420,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":56.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":56.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":56.660,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":56.100,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":56.100,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":56.100,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":84.150,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":58.910,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":56.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":57.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":56.100,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":57.220,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, upper extremity; with contrast material(s) ","code_information":[{"code":"614","type":"RC"},{"code":"73201","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Lithium ","code_information":[{"code":"301","type":"RC"},{"code":"80178","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.180,"maximum":7.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.270,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.610,"methodology":"fee schedule"}]}]},{"description":"Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) ","code_information":[{"code":"305","type":"RC"},{"code":"87210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.440,"maximum":6.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.400,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.820,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.820,"methodology":"fee schedule"}]}]},{"description":"Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"64473","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body, shoulder; deep (subfascial or intramuscular) ","code_information":[{"code":"23333","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair and reconstruction, finger, volar plate, interphalangeal joint ","code_information":[{"code":"26548","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19952.580,"maximum":19952.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":19952.580,"methodology":"fee schedule"}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle ","code_information":[{"code":"23170","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing t ","code_information":[{"code":"37297","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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, carotid, subclavian artery, by neck incision ","code_information":[{"code":"35002","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Blood count; manual cell count (erythrocyte, leukocyte, or platelet) each ","code_information":[{"code":"312","type":"RC"},{"code":"85032","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.310,"maximum":5.090,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.090,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis; pantalar ","code_information":[{"code":"28705","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"321","type":"RC"},{"code":"74220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":110.290,"maximum":401.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":131.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":149.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":131.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":160.240,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":125.440,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":110.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"C-reactive protein; ","code_information":[{"code":"310","type":"RC"},{"code":"86140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.180,"maximum":6.110,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.110,"methodology":"fee schedule"}]}]},{"description":"Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract ","code_information":[{"code":"47760","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Immunoglobulin light chains (ie, kappa, lambda), free, each ","code_information":[{"code":"310","type":"RC"},{"code":"83521","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.270,"maximum":20.380,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.380,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C ","code_information":[{"code":"143","type":"RC"},{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9205.250,"maximum":12738.800,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9205.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Xwrap plus, per square  centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical ","code_information":[{"code":"22210","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal ","code_information":[{"code":"20962","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Capsulodesis, metacarpophalangeal joint; single digit ","code_information":[{"code":"26516","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Reduction forehead; contouring only ","code_information":[{"code":"21137","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"154","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27983.840,"maximum":27983.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27983.840,"methodology":"fee schedule"}]}]},{"description":"Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); high definition qualitative panel for identification of antibody specificities (eg, i ","code_information":[{"code":"304","type":"RC"},{"code":"86832","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":302.710,"maximum":382.020,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":302.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":356.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":302.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":356.130,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":323.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":382.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":323.750,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20857.920,"maximum":20857.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20857.920,"methodology":"fee schedule"}]}]},{"description":"Enverse, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; subclavian-vertebral ","code_information":[{"code":"35645","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multi ","code_information":[{"code":"15018","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure) ","code_information":[{"code":"33987","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional 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; lumbar ","code_information":[{"code":"22865","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Resection prosthesis - Maxillary complete removable ","code_information":[{"code":"790","type":"RC"},{"code":"D5938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Nursing care, in the home; by licensed practical nurse, per hour ","code_information":[{"code":"S9124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":140.130,"maximum":140.130,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":140.130,"methodology":"fee schedule"}]}]},{"description":"HAND PROCEDURES FOR INJURIES ","code_information":[{"code":"210","type":"RC"},{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15569.100,"maximum":15569.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15569.100,"methodology":"fee schedule"}]}]},{"description":"Prostatectomy, retropubic radical, with or without nerve sparing; ","code_information":[{"code":"362","type":"RC"},{"code":"55840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Immersion external heater for nebulizer ","code_information":[{"code":"E1372","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":177.740,"maximum":274.860,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":185.070,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":188.740,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":192.400,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":186.900,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":183.240,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":192.400,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":192.400,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":177.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":185.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":185.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":185.070,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":183.240,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":183.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":183.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":177.740,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":274.860,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":192.400,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":183.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":186.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":183.240,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":186.900,"methodology":"fee schedule"}]}]},{"description":"Bone graft, any donor area; major or large ","code_information":[{"code":"20902","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Cranioplasty with autograft (includes obtaining bone grafts); larger than 5 cm diameter ","code_information":[{"code":"62147","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation ","code_information":[{"code":"61698","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiological examination, surgical specimen ","code_information":[{"code":"320","type":"RC"},{"code":"76098","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.060,"maximum":1086.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":60.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":68.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":60.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":73.030,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":17.060,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":46.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":646.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1086.500,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) ","code_information":[{"code":"22614","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Methotrexate ","code_information":[{"code":"303","type":"RC"},{"code":"80204","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.060,"maximum":45.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.430,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":38.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":45.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38.570,"methodology":"fee schedule"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH CC ","code_information":[{"code":"071","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8880.170,"maximum":8880.170,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8880.170,"methodology":"fee schedule"}]}]},{"description":"Inj, nyvepria ","code_information":[{"code":"9406","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":129.060,"maximum":199.580,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":134.380,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":137.050,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":139.710,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":135.720,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":133.050,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":139.710,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":139.710,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":129.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":134.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":134.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":134.380,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":133.050,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":133.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":133.050,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":199.580,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":139.710,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":133.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":135.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":133.050,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":135.720,"methodology":"fee schedule"}]}]},{"description":"Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC ","code_information":[{"code":"122","type":"RC"},{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8076.050,"maximum":8076.050,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8076.050,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15211.940,"maximum":15211.940,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15211.940,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; subclavian-brachial ","code_information":[{"code":"35512","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROST ","code_information":[{"code":"141","type":"RC"},{"code":"518","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28208.400,"maximum":28208.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28208.400,"methodology":"fee schedule"}]}]},{"description":"PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis ","code_information":[{"code":"314","type":"RC"},{"code":"81325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":769.580,"maximum":908.100,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":769.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":908.100,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral ","code_information":[{"code":"360","type":"RC"},{"code":"63283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":12326.500,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Bilirubin; feces, qualitative ","code_information":[{"code":"82252","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4.260,"maximum":5.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.020,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.560,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"816","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6071.440,"maximum":6071.440,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6071.440,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS ","code_information":[{"code":"029","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":25886.560,"maximum":25886.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":25886.560,"methodology":"fee schedule"}]}]},{"description":"Innovamatrix ac, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"A2001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) ","code_information":[{"code":"40819","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH CC ","code_information":[{"code":"209","type":"RC"},{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9788.380,"maximum":9788.380,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9788.380,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"127","type":"RC"},{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14134.070,"maximum":14134.070,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14134.070,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique ","code_information":[{"code":"302","type":"RC"},{"code":"87485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.750,"maximum":23.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.050,"methodology":"fee schedule"}]}]},{"description":"Artacent c, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Oncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalinfixed paraffin-embedded ","code_information":[{"code":"0586U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2729.830,"maximum":3445.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2729.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3211.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2729.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3211.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3445.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2919.600,"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Intersex surgery; female to male ","code_information":[{"code":"55980","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DENTAL AND ORAL DISEASES WITHOUT CC/MCC ","code_information":[{"code":"124","type":"RC"},{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6616.790,"maximum":6616.790,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6616.790,"methodology":"fee schedule"}]}]},{"description":"Transcervical instillation of biodegradable hydrogel materials, intrauterine ","code_information":[{"code":"0990T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":3348.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal) ","code_information":[{"code":"42844","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC ","code_information":[{"code":"056","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11057.990,"maximum":11969.990,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":11969.990,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":11057.990,"methodology":"fee schedule"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC ","code_information":[{"code":"206","type":"RC"},{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":36772.200,"maximum":36772.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":36772.200,"methodology":"fee schedule"}]}]},{"description":"Ziconotide injection ","code_information":[{"code":"1694","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":10.250,"maximum":15.850,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":10.670,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":10.880,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":11.090,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":10.560,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":11.090,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":11.090,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":10.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10.670,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":10.670,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":10.670,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":10.560,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":10.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":10.560,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":15.850,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11.090,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":10.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":10.560,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":10.780,"methodology":"fee schedule"}]}]},{"description":"Removal, under anesthesia, of external fixation system ","code_information":[{"code":"20694","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Removal of foreign body in scrotum ","code_information":[{"code":"55120","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Phenylketones, qualitative ","code_information":[{"code":"84035","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3.720,"maximum":4.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.980,"methodology":"fee schedule"}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motionºs» and/or ejection fractionºs», when performed); multiple studies at rest and stress (exercis ","code_information":[{"code":"616","type":"RC"},{"code":"78492","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1721.140,"maximum":1721.140,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1721.140,"methodology":"fee schedule"}]}]},{"description":"Pharyngostomy (fistulization of pharynx, external for feeding) ","code_information":[{"code":"362","type":"RC"},{"code":"42955","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod ","code_information":[{"code":"26390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14021.660,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14021.660,"methodology":"fee schedule"}]}]},{"description":"HLA Class II typing, low resolution (eg, antigen equivalents); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each ","code_information":[{"code":"314","type":"RC"},{"code":"81376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":122.220,"maximum":144.220,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":122.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":144.220,"methodology":"fee schedule"}]}]},{"description":"Injection procedure for discography, each level; lumbar ","code_information":[{"code":"62290","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ORTHOPEDIC; M > 44.75 ","code_information":[{"code":"024","type":"RC"},{"code":"C0901","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":15119.370,"maximum":15119.370,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":15119.370,"methodology":"fee schedule"}]}]},{"description":"Venography, adrenal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"612","type":"RC"},{"code":"75840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.050,"maximum":3714.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3714.050,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; sternum, minimum of 2 views ","code_information":[{"code":"322","type":"RC"},{"code":"71120","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":33.520,"maximum":40.760,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":33.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":33.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":40.760,"methodology":"fee schedule"}]}]},{"description":"HYPERTENSION WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6948.990,"maximum":6948.990,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6948.990,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) ","code_information":[{"code":"28313","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC ","code_information":[{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4635.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2866.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":2150.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":2866.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2866.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4635.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"TRAUMATIC SPINAL CORD INJURY; M < 16.05 & A > 63.5 ","code_information":[{"code":"138","type":"RC"},{"code":"B0404","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":49659.810,"maximum":56827.210,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":54267.420,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":51195.680,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":56827.210,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":53755.470,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":49659.810,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":51707.640,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":51707.640,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":51707.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":51195.680,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":56827.210,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":56827.210,"methodology":"fee schedule"}]}]},{"description":"Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) ","code_information":[{"code":"367","type":"RC"},{"code":"65435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Manipulation, elbow, under anesthesia ","code_information":[{"code":"24300","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with laparoscopic pyloric dr ","code_information":[{"code":"43288","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision ","code_information":[{"code":"88152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.860,"maximum":41.460,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":24.880,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":24.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":24.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":24.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":24.880,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":15.600,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":28.470,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":15.160,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":38.970,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":28.190,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":22.290,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":26.810,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":33.170,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":23.670,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":14.860,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":41.460,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":28.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":28.190,"methodology":"fee schedule"}]}]},{"description":"Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including intestine anastomosis ","code_information":[{"code":"369","type":"RC"},{"code":"50810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less ","code_information":[{"code":"11042","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":39805.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37122.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32724.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39805.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":130.00,"standard_charge_algorithm":"Reimbursement will be 130% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. Zero instances of this service in the last 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":"AllPayerAppendix","standard_charge_dollar":30900.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transurethral destruction of prostate tissue; by radiofrequency thermotherapy ","code_information":[{"code":"367","type":"RC"},{"code":"53852","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy with biopsy; intertarsal or tarsometatarsal joint ","code_information":[{"code":"28050","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Osteotomy; tibia and fibula ","code_information":[{"code":"27709","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) ","code_information":[{"code":"28262","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":12326.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Partial exchange transfusion, blood, plasma or crystalloid necessitating the skill of a physician or other qualified health care professional, newborn ","code_information":[{"code":"36456","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheteriz ","code_information":[{"code":"37281","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed ","code_information":[{"code":"37225","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2808.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"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 ","code_information":[{"code":"137","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15583.360,"maximum":15583.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15583.360,"methodology":"fee schedule"}]}]},{"description":"Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s) ","code_information":[{"code":"15730","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8193.670,"maximum":8193.670,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8193.670,"methodology":"fee schedule"}]}]},{"description":"Exploration with removal of deep foreign body, forearm or wrist ","code_information":[{"code":"25248","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Manipulation, wrist, under anesthesia ","code_information":[{"code":"25259","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial ma ","code_information":[{"code":"43253","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (include ","code_information":[{"code":"33958","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thyroidectomy, total or subtotal for malignancy; with radical neck dissection ","code_information":[{"code":"360","type":"RC"},{"code":"60254","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"400","type":"RC"},{"code":"74175","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":112.500,"maximum":136.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":112.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":127.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":112.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":136.820,"methodology":"fee schedule"}]}]},{"description":"FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability ºXLID») gene analysis; characterization of alleles (eg, expanded size and promoter methylation ","code_information":[{"code":"302","type":"RC"},{"code":"81244","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.970,"maximum":52.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":49.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.380,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":44.890,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":52.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":44.890,"methodology":"fee schedule"}]}]},{"description":"IDH1 (isocitrate dehydrogenase 1 ºNADP+», soluble) (eg, glioma), common variants (eg, R132H, R132C) ","code_information":[{"code":"81120","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":180.690,"maximum":228.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":180.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":212.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":228.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":193.250,"methodology":"fee schedule"}]}]},{"description":"STROKE; M > 30.05 & M < 34.25 ","code_information":[{"code":"158","type":"RC"},{"code":"D0106","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":35627.180,"maximum":40769.250,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":38932.800,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":36729.050,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":40769.250,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":38565.510,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":35627.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":37096.340,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":37096.340,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":37096.340,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":36729.050,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":40769.250,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":40769.250,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, pelvis; with contrast material(s) ","code_information":[{"code":"351","type":"RC"},{"code":"72193","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":401.740,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC ","code_information":[{"code":"082","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":17859.570,"maximum":17859.570,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17859.570,"methodology":"fee schedule"}]}]},{"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":"369","type":"RC"},{"code":"66982","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3906.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3245.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3869.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2987.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Oncology, spheroid cell culture in 3D microenvironment, 12 drug panel, response prediction for each drug ","code_information":[{"code":"0248U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2836.660,"maximum":3579.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2836.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3337.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2836.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3337.250,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3033.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3579.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3033.860,"methodology":"fee schedule"}]}]},{"description":"Endovascular placement of iliac artery occlusion device (List separately in addition to code for primary procedure) ","code_information":[{"code":"34808","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0DL67DZ","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17510.000,"maximum":17510.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17510.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) ","code_information":[{"code":"32667","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11066.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Venography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"351","type":"RC"},{"code":"75820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1833.060,"maximum":1833.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1833.060,"methodology":"fee schedule"}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"209","type":"RC"},{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7772.360,"maximum":7772.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7772.360,"methodology":"fee schedule"}]}]},{"description":"Aquaporin-4 (neuromyelitis optica ºNMO») antibody; flow cytometry (ie, fluorescence-activated cell sorting ºFACS»), each ","code_information":[{"code":"312","type":"RC"},{"code":"86053","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.730,"maximum":44.520,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":37.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":44.520,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8512.330,"maximum":8512.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8512.330,"methodology":"fee schedule"}]}]},{"description":"MAJOR SKIN DISORDERS ","code_information":[{"code":"3814","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15701.300,"maximum":23551.950,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":15701.300,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":16015.330,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":23551.950,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":15701.300,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":15701.300,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":15701.300,"methodology":"fee schedule"}]}]},{"description":"MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants ","code_information":[{"code":"309","type":"RC"},{"code":"81293","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":309.490,"maximum":390.580,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":309.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":364.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":309.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":364.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":331.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":390.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":331.000,"methodology":"fee schedule"}]}]},{"description":"Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J2274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":29.030,"maximum":29.030,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.030,"methodology":"fee schedule"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) ","code_information":[{"code":"610","type":"RC"},{"code":"78709","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"REMOVE BILE DUCT STONE ","code_information":[{"code":"369","type":"RC"},{"code":"47630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour ","code_information":[{"code":"96365","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":529.820,"maximum":551.900,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":540.860,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":551.900,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":529.820,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":540.860,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":551.900,"methodology":"fee schedule"}]}]},{"description":"Leukocyte phagocytosis ","code_information":[{"code":"309","type":"RC"},{"code":"86344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.710,"maximum":12.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.430,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10.390,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.390,"methodology":"fee schedule"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC ","code_information":[{"code":"124","type":"RC"},{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12508.720,"maximum":12508.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12508.720,"methodology":"fee schedule"}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"219","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16684.040,"maximum":16684.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16684.040,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8768.960,"maximum":8768.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8768.960,"methodology":"fee schedule"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention ","code_information":[{"code":"614","type":"RC"},{"code":"78707","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Incision, drainage of lacrimal gland ","code_information":[{"code":"480","type":"RC"},{"code":"68400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified ","drug_information":{"unit":1.000000000000000e+000,"type":"UN"},"code_information":[{"code":"636","type":"RC"},{"code":"914604","type":"CDM"},{"code":"J7192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.420,"maximum":3.420,"gross_charge":15.58,"discounted_cash":15.58,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.420,"methodology":"fee schedule"}]}]},{"description":"Thoracic fascial plane block, unilateral; by injection(s), including imaging guidance, when performed ","code_information":[{"code":"362","type":"RC"},{"code":"64466","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"404","type":"RC"},{"code":"72133","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus ","code_information":[{"code":"61544","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"146","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12140.880,"maximum":12140.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12140.880,"methodology":"fee schedule"}]}]},{"description":"Exploration of epididymis, with or without biopsy ","code_information":[{"code":"367","type":"RC"},{"code":"54865","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hepatitis A vaccine (HepA), adult dosage, for intramuscular use ","code_information":[{"code":"891","type":"RC"},{"code":"90632","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":158.110,"maximum":158.110,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":158.110,"methodology":"fee schedule"}]}]},{"description":"Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use ","code_information":[{"code":"636","type":"RC"},{"code":"90375","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":601.890,"maximum":601.890,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":601.890,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) ","code_information":[{"code":"25520","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, flexible; diagnostic ","code_information":[{"code":"31575","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision ","code_information":[{"code":"314","type":"RC"},{"code":"88148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.600,"maximum":21.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.000,"methodology":"fee schedule"}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15318.160,"maximum":15318.160,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15318.160,"methodology":"fee schedule"}]}]},{"description":"ATHEROSCLEROSIS WITHOUT MCC ","code_information":[{"code":"147","type":"RC"},{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6365.140,"maximum":6365.140,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6365.140,"methodology":"fee schedule"}]}]},{"description":"Protein, total, except by refractometry; urine ","code_information":[{"code":"84156","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3.430,"maximum":4.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.040,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.670,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of nail bed with graft ","code_information":[{"code":"11762","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC ","code_information":[{"code":"132","type":"RC"},{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":55886.560,"maximum":55886.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":55886.560,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, lower extremity, with or without contrast material(s) ","code_information":[{"code":"402","type":"RC"},{"code":"73725","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":599.890,"maximum":599.890,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":599.890,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"206","type":"RC"},{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22553.870,"maximum":22553.870,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22553.870,"methodology":"fee schedule"}]}]},{"description":"Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial ","code_information":[{"code":"480","type":"RC"},{"code":"61321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"72196","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":310.680,"maximum":503.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":375.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":425.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":375.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":456.140,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":503.090,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":310.680,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints ","code_information":[{"code":"21470","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Suture of mesentery (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"44850","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Trabecular bone score (TBS), structural condition of the bone microarchitecture; technical calculation only ","code_information":[{"code":"321","type":"RC"},{"code":"77091","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.150,"maximum":185.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.950,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":30.150,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.870,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Babesia microti, amplified probe technique ","code_information":[{"code":"312","type":"RC"},{"code":"87469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":41.410,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"}]}]},{"description":"Excision of neurofibroma or neurolemmoma; cutaneous nerve ","code_information":[{"code":"64788","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":" Radiology - Therapeutic and/or Chemotherapy Administration Chemotherapy Admin - IV  ","code_information":[{"code":"335","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":618.000,"maximum":3728.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3065.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3477.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3065.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3728.480,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":3596.800,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":618.000,"methodology":"case rate"}]}]},{"description":"Dermabrasion; regional, other than face ","code_information":[{"code":"15782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7334.440,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7041.060,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":7334.440,"methodology":"fee schedule"}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"514","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5394.020,"maximum":5838.890,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":5838.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":5394.020,"methodology":"fee schedule"}]}]},{"description":"Treatment of superficial wound dehiscence; with packing ","code_information":[{"code":"12021","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":31482.640,"maximum":31482.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":31482.640,"methodology":"fee schedule"}]}]},{"description":"RENAL FAILURE WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12123.760,"maximum":12123.760,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12123.760,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, i ","code_information":[{"code":"360","type":"RC"},{"code":"92938","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":10520.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass ","code_information":[{"code":"33265","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure) ","code_information":[{"code":"0071U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":561.000,"maximum":708.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":561.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":660.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":561.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":660.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":600.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":708.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":600.000,"methodology":"fee schedule"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"209","type":"RC"},{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12988.480,"maximum":12988.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12988.480,"methodology":"fee schedule"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16812.360,"maximum":16812.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16812.360,"methodology":"fee schedule"}]}]},{"description":"Glial fibrillary acidic protein (GFAP), chemiluminescent enzyme immunoassay, using plasma ","code_information":[{"code":"0548U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":108.680,"maximum":137.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":108.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":127.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":108.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":127.850,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":116.230,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":137.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":116.230,"methodology":"fee schedule"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"66630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH CC ","code_information":[{"code":"213","type":"RC"},{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20069.490,"maximum":20069.490,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20069.490,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views ","code_information":[{"code":"400","type":"RC"},{"code":"73502","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":53.890,"maximum":65.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":53.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":53.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":65.540,"methodology":"fee schedule"}]}]},{"description":"Folic acid; serum ","code_information":[{"code":"305","type":"RC"},{"code":"82746","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.740,"maximum":17.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.170,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.700,"methodology":"fee schedule"}]}]},{"description":"Antibody; encephalitis, California (La Crosse) ","code_information":[{"code":"314","type":"RC"},{"code":"86651","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.190,"maximum":15.560,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.560,"methodology":"fee schedule"}]}]},{"description":"INJECT SPINE W/CATH LMB/SCRL ","code_information":[{"code":"361","type":"RC"},{"code":"62319","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"616","type":"RC"},{"code":"73206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.060,"maximum":210.060,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10006","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) ","code_information":[{"code":"43214","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture of; brachial plexus ","code_information":[{"code":"499","type":"RC"},{"code":"64861","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Removal, non-biodegradable drug delivery implant ","code_information":[{"code":"11982","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Osmolality; urine ","code_information":[{"code":"303","type":"RC"},{"code":"83935","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.380,"maximum":8.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.820,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.820,"methodology":"fee schedule"}]}]},{"description":"BREAST RECONSTRUCTION WITH OTHER TECHNIQUE ","code_information":[{"code":"19366","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":11468.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Aquaporin-4 (neuromyelitis optica ºNMO») antibody; enzyme-linked immunosorbent immunoassay (ELISA) ","code_information":[{"code":"306","type":"RC"},{"code":"86051","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.780,"maximum":13.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.530,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision ","code_information":[{"code":"88165","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":49.820,"maximum":49.820,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":49.820,"methodology":"fee schedule"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; with repair of annular defect by implan ","code_information":[{"code":"63032","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALLERGIC REACTIONS WITHOUT MCC ","code_information":[{"code":"150","type":"RC"},{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6315.960,"maximum":6315.960,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6315.960,"methodology":"fee schedule"}]}]},{"description":"Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial ","code_information":[{"code":"61321","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; ","code_information":[{"code":"69660","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure) ","code_information":[{"code":"0133U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":645.420,"maximum":814.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":645.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":759.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":645.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":759.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":690.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":814.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":690.290,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"329","type":"RC"},{"code":"71552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":899.810,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":653.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":741.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":653.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":795.070,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":899.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation ","code_information":[{"code":"21432","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC ","code_information":[{"code":"213","type":"RC"},{"code":"485","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24571.300,"maximum":24571.300,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24571.300,"methodology":"fee schedule"}]}]},{"description":"Phencyclidine (PCP) ","code_information":[{"code":"301","type":"RC"},{"code":"83992","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":38.820,"maximum":45.670,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":38.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":45.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":38.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":41.520,"methodology":"fee schedule"}]}]},{"description":"Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial ","code_information":[{"code":"343","type":"RC"},{"code":"J3240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4570.130,"maximum":4570.130,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4570.130,"methodology":"fee schedule"}]}]},{"description":"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES ","code_information":[{"code":"2601","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10361.580,"maximum":15542.370,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":10361.580,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":10568.810,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":15542.370,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":10361.580,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":10361.580,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":10361.580,"methodology":"fee schedule"}]}]},{"description":"Deoxyribonucleic acid (DNA) antibody, double stranded, high avidity ","code_information":[{"code":"0039U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13.740,"maximum":16.210,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.210,"methodology":"fee schedule"}]}]},{"description":"Impression and custom preparation; interim obturator prosthesis ","code_information":[{"code":"21079","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH ","code_information":[{"code":"111","type":"RC"},{"code":"410","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12884.400,"maximum":12884.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12884.400,"methodology":"fee schedule"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC ","code_information":[{"code":"147","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":10630.290,"maximum":10630.290,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10630.290,"methodology":"fee schedule"}]}]},{"description":"Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment ","code_information":[{"code":"362","type":"RC"},{"code":"61026","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"172","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7043.090,"maximum":7043.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7043.090,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22139.680,"maximum":22139.680,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22139.680,"methodology":"fee schedule"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or ","code_information":[{"code":"481","type":"RC"},{"code":"63035","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Heparin assay ","code_information":[{"code":"301","type":"RC"},{"code":"85520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.240,"maximum":15.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.400,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.090,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, foot; 2 views ","code_information":[{"code":"341","type":"RC"},{"code":"73620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of distal radioulnar dislocation with manipulation ","code_information":[{"code":"25675","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, lower extremity; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"73701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":191.630,"maximum":322.430,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":231.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":262.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":231.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":281.830,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":322.430,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":191.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"}]}]},{"description":"Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess) ","code_information":[{"code":"26992","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed ","code_information":[{"code":"64446","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Impression and custom preparation; auricular prosthesis ","code_information":[{"code":"21086","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"206","type":"RC"},{"code":"855","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12239.250,"maximum":12239.250,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12239.250,"methodology":"fee schedule"}]}]},{"description":"Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification ","code_information":[{"code":"350","type":"RC"},{"code":"78473","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":474.160,"maximum":474.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10472.600,"maximum":12738.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11880.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10472.600,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12738.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12288.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery ","code_information":[{"code":"54057","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Genome, rapid sequence analysis, each comparator genome ","code_information":[{"code":"0425U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3828.250,"maximum":4831.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3828.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4503.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3828.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4503.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4831.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4094.390,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical ","code_information":[{"code":"369","type":"RC"},{"code":"63270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"HEART FAILURE AND SHOCK WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7618.380,"maximum":7618.380,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7618.380,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3811.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3811.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"Correction of everted punctum, cautery ","code_information":[{"code":"68705","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (solid tumor as indicated by the label), somatic mutation analyis of BRCA1, BRCA2 and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, a ","code_information":[{"code":"0172U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2833.050,"maximum":3575.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2833.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3333.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2833.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3333.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3030.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3575.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3030.000,"methodology":"fee schedule"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13450.430,"maximum":13450.430,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13450.430,"methodology":"fee schedule"}]}]},{"description":"Esophagectomy, distal two-thirds, with laparoscopic mobilization of the abdominal and lower mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, w ","code_information":[{"code":"43287","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":11066.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"SALIVARY GLAND PROCEDURES ","code_information":[{"code":"139","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":10375.080,"maximum":10375.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10375.080,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"137","type":"RC"},{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13712.050,"maximum":13712.050,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13712.050,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, phalanges of foot ","code_information":[{"code":"28108","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of a temporary prostatic urethral stent, including urethral measurement ","code_information":[{"code":"360","type":"RC"},{"code":"53855","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA ","code_information":[{"code":"121","type":"RC"},{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":71305.370,"maximum":71305.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":71305.370,"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":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Proctosigmoidoscopy, rigid; with removal of foreign body ","code_information":[{"code":"45307","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation ","code_information":[{"code":"361","type":"RC"},{"code":"91035","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1182.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4635.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4635.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"Anabolic steroids; 1 or 2 ","code_information":[{"code":"80327","type":"CPT"},{"code":"822852","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":36.320,"maximum":54.480,"gross_charge":171.75,"discounted_cash":171.75,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":38.140,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":37.050,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":54.480,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":36.320,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of; vagus nerves limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy) ","code_information":[{"code":"499","type":"RC"},{"code":"64755","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, a ","code_information":[{"code":"341","type":"RC"},{"code":"78453","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":307.830,"maximum":354.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":307.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":349.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":307.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":354.860,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8447.460,"maximum":8447.460,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8447.460,"methodology":"fee schedule"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"126","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":7950.580,"maximum":7950.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7950.580,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"71271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":230.930,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":189.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":215.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":189.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":230.930,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":158.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, intestine (except rectum) ","code_information":[{"code":"44238","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Discography, lumbar, radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"72295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2304.270,"maximum":2304.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2304.270,"methodology":"fee schedule"}]}]},{"description":"Injection, ranibizumab, 0.1 mg ","code_information":[{"code":"J2778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":87.700,"maximum":324.770,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":220.320,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":103.980,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":152.910,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":318.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":87.700,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":324.770,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":101.940,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":311.780,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":318.270,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":324.770,"methodology":"fee schedule"}]}]},{"description":"Venous thrombosis imaging, venogram; bilateral ","code_information":[{"code":"321","type":"RC"},{"code":"78458","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":214.370,"maximum":474.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":320.420,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":214.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":474.160,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"200","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6907.640,"maximum":6907.640,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6907.640,"methodology":"fee schedule"}]}]},{"description":"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES ","code_information":[{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":119844.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":109098.810,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":39148.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":109098.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":109098.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":109098.810,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":77927.720,"methodology":"fee schedule"},{"payer_name":"American Steel Products","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":98525.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":111765.640,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":39923.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":98525.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":119844.900,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":48450.940,"methodology":"fee schedule"},{"payer_name":"City of Eastman","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":39535.970,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCD","standard_charge_dollar":32946.640,"methodology":"fee schedule"},{"payer_name":"Compassionate Care Hospice","plan_name":"MCR","standard_charge_dollar":32946.640,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11463.900,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $177788.20, reimbursement will be 37% of billable gross charges instead of the contracted rate."},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":39535.970,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":39535.970,"methodology":"fee schedule"},{"payer_name":"Dodge Co Board of Commissioners","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dodge County Hospital","plan_name":"COMM","standard_charge_percentage":50.00,"standard_charge_algorithm":"Reimbursement will be 50% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":40311.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"First Health","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":59351.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":40311.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Graham Brothers Construction","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":37597.930,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":44513.820,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":39148.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":39148.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":39148.360,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":38760.750,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":38760.750,"methodology":"fee schedule"},{"payer_name":"Hospice of Savannah","plan_name":"COMM","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCR","standard_charge_dollar":38760.750,"methodology":"fee schedule"},{"payer_name":"Leavitt Risk Partners","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Memorial Health Plan","plan_name":"EMPLOYEEPLAN","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 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":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":40311.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12892.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":40311.180,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":58141.130,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":40698.790,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":38760.750,"methodology":"fee schedule"},{"payer_name":"Standard Candy ","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"AllPayerAppendix","standard_charge_dollar":96166.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":37946.770,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.50,"standard_charge_algorithm":"Reimbursement will be 31.5% 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":"VACCN","standard_charge_dollar":38760.750,"methodology":"fee schedule"},{"payer_name":"United Hospice of Swainsboro","plan_name":"COMM","standard_charge_dollar":38760.750,"methodology":"fee schedule"},{"payer_name":"Vidalia Naval Stores","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"VistaCare Hospice","plan_name":"COMM","standard_charge_dollar":400.000,"methodology":"per diem"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":39535.970,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia ","code_information":[{"code":"46045","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial ","code_information":[{"code":"490","type":"RC"},{"code":"61321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12326.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"204","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9176.020,"maximum":9176.020,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9176.020,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS ","code_information":[{"code":"029","type":"MS-DRG"},{"code":"146","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":25886.560,"maximum":25886.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":25886.560,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, segmental or subsegmental pulmonary artery ","code_information":[{"code":"36015","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":" Continuous Ambulatory Peritoneal Dialysis - Outpatient or Home - Composite or Other Rate  ","code_information":[{"code":"841","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":258.000,"maximum":1856.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1526.040,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1731.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1526.040,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1856.270,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":1790.720,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":258.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of femoral shaft fracture, without manipulation ","code_information":[{"code":"27500","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL73DZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3296.000,"maximum":3296.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3296.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"117","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27983.840,"maximum":27983.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27983.840,"methodology":"fee schedule"}]}]},{"description":"Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) ","code_information":[{"code":"24346","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple ","code_information":[{"code":"367","type":"RC"},{"code":"46607","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, lenacapavir (only for use as hiv treatment), 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J1961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":47.950,"maximum":47.950,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":47.950,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includ ","code_information":[{"code":"33963","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision, lower extremity arterial bypass, without thrombectomy, open; with vein patch angioplasty ","code_information":[{"code":"35879","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps ","code_information":[{"code":"31030","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC ","code_information":[{"code":"210","type":"RC"},{"code":"929","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24526.400,"maximum":24526.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24526.400,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments ","code_information":[{"code":"22800","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC ","code_information":[{"code":"053","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8546.550,"maximum":8546.550,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8546.550,"methodology":"fee schedule"}]}]},{"description":"Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) ","code_information":[{"code":"0089U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":710.600,"maximum":896.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":710.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":836.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation ","code_information":[{"code":"20805","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Exchange of intraocular lens ","code_information":[{"code":"361","type":"RC"},{"code":"66986","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair of enterocele, vaginal approach (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"57268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube ","code_information":[{"code":"68745","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Desoxycorticosterone, 11- ","code_information":[{"code":"82633","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28.970,"maximum":36.560,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":28.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":34.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":28.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30.980,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/ ","code_information":[{"code":"022","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":24217.010,"maximum":24217.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24217.010,"methodology":"fee schedule"}]}]},{"description":"CSTB (cystatin B), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, Short Tandem Requests (STR) expansions, mobile element insertions, and ","code_information":[{"code":"0232U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":256.970,"maximum":324.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":256.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":302.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"084","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8379.730,"maximum":8379.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8379.730,"methodology":"fee schedule"}]}]},{"description":"Repair blood vessel, direct; lower extremity ","code_information":[{"code":"35226","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process ","code_information":[{"code":"24147","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8413.240,"maximum":8413.240,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8413.240,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open ","code_information":[{"code":"24358","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; with cardiopulmonary bypass ","code_information":[{"code":"33853","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair ","code_information":[{"code":"40812","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITH VAGOTOMY ","code_information":[{"code":"43855","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Blepharotomy, drainage of abscess, eyelid ","code_information":[{"code":"67700","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10138.400,"maximum":10138.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10138.400,"methodology":"fee schedule"}]}]},{"description":"Gabapentin, whole blood, serum, or plasma ","code_information":[{"code":"301","type":"RC"},{"code":"80171","type":"CPT"},{"code":"804825","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":20.260,"maximum":25.570,"gross_charge":1165.25,"discounted_cash":1165.25,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.840,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.670,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":25.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.670,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; orchiopexy for intra-abdominal testis ","code_information":[{"code":"54692","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":14369.190,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5690.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13794.420,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":14369.190,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13559.500,"maximum":13559.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13559.500,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"172","type":"RC"},{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14346.510,"maximum":14346.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":14346.510,"methodology":"fee schedule"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY ","code_information":[{"code":"124","type":"RC"},{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13035.530,"maximum":13035.530,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13035.530,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification ","code_information":[{"code":"312","type":"RC"},{"code":"87482","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.740,"maximum":65.770,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":55.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":65.770,"methodology":"fee schedule"}]}]},{"description":"Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision ","code_information":[{"code":"34201","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH CC ","code_information":[{"code":"117","type":"RC"},{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9527.470,"maximum":15285.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9527.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14254.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12565.900,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15285.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":14745.300,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach ","code_information":[{"code":"57423","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":24891.330,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":24393.500,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":24891.330,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":23895.680,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":24393.500,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":24891.330,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SIGNS AND SYMPTOMS ","code_information":[{"code":"101","type":"RC"},{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7321.830,"maximum":7321.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7321.830,"methodology":"fee schedule"}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24652.570,"maximum":24652.570,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24652.570,"methodology":"fee schedule"}]}]},{"description":"Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"49440","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Infusion, normal saline solution, 250 cc ","code_information":[{"code":"J7050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.600,"maximum":1.200,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":0.790,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":0.820,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":1.200,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":0.600,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":0.800,"methodology":"fee schedule"}]}]},{"description":"Phenytoin; total ","code_information":[{"code":"300","type":"RC"},{"code":"80185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.390,"maximum":15.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.250,"methodology":"fee schedule"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"66625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"143","type":"MS-DRG"},{"code":"212","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":28274.700,"maximum":28274.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28274.700,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/ ","code_information":[{"code":"123","type":"RC"},{"code":"941","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16021.060,"maximum":16021.060,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16021.060,"methodology":"fee schedule"}]}]},{"description":"Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, renin), radiological supervision and interpretation ","code_information":[{"code":"341","type":"RC"},{"code":"75893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6378.730,"maximum":6378.730,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6378.730,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents ","code_information":[{"code":"619","type":"RC"},{"code":"C8933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":828.270,"maximum":828.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only ","code_information":[{"code":"369","type":"RC"},{"code":"43773","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":25853.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21254.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24111.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21254.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25853.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":24940.800,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16480.000,"methodology":"case rate"}]}]},{"description":"Cardiac shunt detection ","code_information":[{"code":"340","type":"RC"},{"code":"78428","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":192.340,"maximum":221.730,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":192.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":218.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":192.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":221.730,"methodology":"fee schedule"}]}]},{"description":"LIVER TRANSPLANT WITHOUT MCC ","code_information":[{"code":"006","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":34622.160,"maximum":34622.160,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":34622.160,"methodology":"fee schedule"}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20528.580,"maximum":20528.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20528.580,"methodology":"fee schedule"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"143","type":"RC"},{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11035.200,"maximum":11035.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11035.200,"methodology":"fee schedule"}]}]},{"description":"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions ","code_information":[{"code":"11057","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6663.840,"maximum":6663.840,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6663.840,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC ","code_information":[{"code":"040","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":29091.650,"maximum":29091.650,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":29091.650,"methodology":"fee schedule"}]}]},{"description":"Tubing with integrated heating element for use with positive airway pressure device ","code_information":[{"code":"A4604","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":66.690,"maximum":103.130,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":69.440,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":70.810,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":72.190,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":70.130,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":68.750,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":72.190,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":72.190,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":66.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":69.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":69.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":69.440,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":68.750,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":68.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":68.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":66.690,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":103.130,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":72.190,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":68.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":70.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":68.750,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":70.130,"methodology":"fee schedule"}]}]},{"description":"Claviculectomy; partial ","code_information":[{"code":"23120","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2484.000,"methodology":"case rate"}]}]},{"description":"Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75885","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":85.400,"maximum":103.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":85.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":96.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":85.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":103.860,"methodology":"fee schedule"}]}]},{"description":"Repair of symblepharon; conjunctivoplasty, without graft ","code_information":[{"code":"490","type":"RC"},{"code":"68330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method ","code_information":[{"code":"43255","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments ","code_information":[{"code":"480","type":"RC"},{"code":"63101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Osteopathic manipulative treatment (OMT); 9-10 body regions involved ","code_information":[{"code":"98929","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":63.620,"maximum":66.270,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":64.940,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":66.270,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":63.620,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":64.940,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":66.270,"methodology":"fee schedule"}]}]},{"description":"URINARY STONES WITHOUT MCC ","code_information":[{"code":"0WFRXZZ","type":"ICD"},{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9673.000,"maximum":9673.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9673.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Computed tomography, thorax, diagnostic; with contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"71260","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":159.900,"maximum":194.470,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":159.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":181.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":159.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":194.470,"methodology":"fee schedule"}]}]},{"description":"Bone graft with microvascular anastomosis; iliac crest ","code_information":[{"code":"20956","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR WITHOUT LYSIS OF ARTERY; FEMORAL ARTERY ","code_information":[{"code":"35721","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7411.200,"maximum":7411.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii ","code_information":[{"code":"309","type":"RC"},{"code":"87281","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.200,"maximum":14.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.980,"methodology":"fee schedule"}]}]},{"description":"Inj talimogene laherparep ","code_information":[{"code":"9472","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":71.720,"maximum":110.910,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":74.680,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":76.160,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":77.640,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":75.420,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":73.940,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":77.640,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":77.640,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":71.720,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":74.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":74.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":74.680,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":73.940,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":73.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":73.940,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":110.910,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":77.640,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":73.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":75.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":73.940,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":75.420,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; intermediate ","code_information":[{"code":"612","type":"RC"},{"code":"77762","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.600,"maximum":682.600,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":682.600,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20047.390,"maximum":20047.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20047.390,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9837.570,"maximum":9837.570,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9837.570,"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":"87206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.620,"maximum":9.380,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":4.850,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":5.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":4.850,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":4.850,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":4.850,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4.850,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":5.550,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5.500,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":9.380,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":5.500,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":8.080,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":5.230,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":6.470,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":5.440,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":4.620,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":8.080,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":5.390,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":5.500,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) ","code_information":[{"code":"323","type":"RC"},{"code":"74182","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":313.300,"maximum":381.020,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":313.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":355.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":313.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":381.020,"methodology":"fee schedule"}]}]},{"description":"Venous anastomosis, open; portocaval ","code_information":[{"code":"367","type":"RC"},{"code":"37140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array an ","code_information":[{"code":"81405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":271.220,"maximum":452.030,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":271.220,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":271.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":271.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":271.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":271.220,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":310.390,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":307.380,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":424.900,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":307.380,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":452.030,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":292.310,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":361.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":304.360,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":452.030,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":316.420,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":307.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":307.380,"methodology":"fee schedule"}]}]},{"description":"Quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary computed tomo ","code_information":[{"code":"400","type":"RC"},{"code":"75577","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1433.120,"maximum":2138.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1433.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1625.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1433.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1742.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2138.630,"methodology":"fee schedule"}]}]},{"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator ","code_information":[{"code":"33217","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9657.000,"maximum":40306.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":30229.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40306.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40306.000,"methodology":"case rate"}]}]},{"description":"Excision of cervical stump, vaginal approach; with repair of enterocele ","code_information":[{"code":"490","type":"RC"},{"code":"57556","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary proce ","code_information":[{"code":"20933","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation ","code_information":[{"code":"24582","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy with adjunctive blue light cystoscopy with fluorescent imaging agent ","code_information":[{"code":"790","type":"RC"},{"code":"C7554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7284.450,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral ","code_information":[{"code":"480","type":"RC"},{"code":"63273","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) ","code_information":[{"code":"340","type":"RC"},{"code":"78708","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":73.280,"maximum":84.470,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":73.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":83.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":73.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":84.470,"methodology":"fee schedule"}]}]},{"description":"Krukenberg procedure ","code_information":[{"code":"25915","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":45203.390,"maximum":45203.390,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":45203.390,"methodology":"fee schedule"}]}]},{"description":"Peritoneal lavage, including imaging guidance, when performed ","code_information":[{"code":"49084","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Appendectomy; for ruptured appendix with abscess or generalized peritonitis ","code_information":[{"code":"44960","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Neurology (Alzheimer Disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0289U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":896.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":896.800,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; common carotid-ipsilateral internal carotid ","code_information":[{"code":"35601","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Sialic acid ","code_information":[{"code":"302","type":"RC"},{"code":"84275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.570,"maximum":15.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.780,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.440,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16255.600,"maximum":16255.600,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16255.600,"methodology":"fee schedule"}]}]},{"description":"Special teletherapy port plan, particles, hemibody, total body ","code_information":[{"code":"322","type":"RC"},{"code":"77321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":105.180,"maximum":431.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":131.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":148.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":131.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":159.700,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":105.180,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":431.960,"methodology":"fee schedule"}]}]},{"description":"Infectious disease, bacterial vaginosis and vaginitis, real-time PCR amplification of DNA markers for Atopobium vaginae, Atopobium species, Megasphaera type 1, and Bacterial Vaginosis Associated Bacte ","code_information":[{"code":"81515","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":245.900,"maximum":310.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":245.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":289.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":245.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":289.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":262.990,"methodology":"fee schedule"}]}]},{"description":"Keratoplasty (corneal transplant); penetrating (in aphakia) ","code_information":[{"code":"361","type":"RC"},{"code":"65750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"56515","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA ","code_information":[{"code":"216","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":51829.340,"maximum":56103.930,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":56103.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":51829.340,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed ","code_information":[{"code":"369","type":"RC"},{"code":"58548","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":24184.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":18137.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24184.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); with O2 saturation, by direct measurement, except pulse oximetry ","code_information":[{"code":"806763","type":"CDM"},{"code":"82805","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.930,"maximum":118.160,"gross_charge":1078.50,"discounted_cash":1078.50,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":70.890,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":79.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":70.890,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":70.890,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":70.890,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":70.890,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":41.930,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":81.130,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":40.730,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":82.710,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":111.070,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":80.350,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":59.890,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":78.770,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":82.710,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":82.710,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":76.410,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":94.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":79.560,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":79.560,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":79.560,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":78.770,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":78.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":78.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":67.450,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":39.930,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":118.160,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":82.710,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":78.770,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":80.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":78.770,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":80.350,"methodology":"fee schedule"}]}]},{"description":"MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medica ","code_information":[{"code":"323","type":"RC"},{"code":"76019","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":37.680,"maximum":45.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.820,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn ","code_information":[{"code":"31520","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney ","code_information":[{"code":"50225","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens ","code_information":[{"code":"68340","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Plastic repair of salivary duct, sialodochoplasty; primary or simple ","code_information":[{"code":"42500","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"123","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8418.940,"maximum":8418.940,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8418.940,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12034.660,"maximum":12034.660,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12034.660,"methodology":"fee schedule"}]}]},{"description":"Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood) ","code_information":[{"code":"319","type":"RC"},{"code":"87102","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.410,"maximum":9.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.920,"methodology":"fee schedule"}]}]},{"description":"Antibody; encephalitis, Western equine ","code_information":[{"code":"307","type":"RC"},{"code":"86654","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.330,"maximum":15.560,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.510,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.190,"methodology":"fee schedule"}]}]},{"description":"Complete (cbc), automated (hgb, hct, rbc, wbc; without platelet count) ","code_information":[{"code":"301","type":"RC"},{"code":"G0307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6.050,"maximum":7.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.120,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.470,"methodology":"fee schedule"}]}]},{"description":"Pleurectomy, parietal (separate procedure) ","code_information":[{"code":"32310","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of cyst or adenoma of thyroid, or transection of isthmus ","code_information":[{"code":"369","type":"RC"},{"code":"60200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, wrist, arthrography, radiological supervision and interpretation ","code_information":[{"code":"616","type":"RC"},{"code":"73115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.410,"maximum":421.410,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23098.510,"maximum":23098.510,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":23098.510,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) ","code_information":[{"code":"0029U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":694.020,"maximum":875.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":694.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":816.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":694.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":816.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":742.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":875.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":742.270,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, mastoids; less than 3 views per side ","code_information":[{"code":"401","type":"RC"},{"code":"70120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH CC Pediatric","code_information":[{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":30065.310,"maximum":42090.280,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":42090.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":42090.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":42090.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":42090.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":30065.310,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and a ","code_information":[{"code":"367","type":"RC"},{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4178.000,"maximum":9657.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft) ","code_information":[{"code":"24435","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"PROCEDURES FOR OBESITY ","code_information":[{"code":"4031","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8772.380,"maximum":13158.570,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":8772.380,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":8947.830,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":13158.570,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":8772.380,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":8772.380,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":8772.380,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC ","code_information":[{"code":"212","type":"RC"},{"code":"728","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7348.910,"maximum":7348.910,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7348.910,"methodology":"fee schedule"}]}]},{"description":"Quantitation of therapeutic drug, not elsewhere specified ","code_information":[{"code":"311","type":"RC"},{"code":"80299","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.640,"maximum":22.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.000,"methodology":"fee schedule"}]}]},{"description":"Myelography, cervical, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"72240","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":58.310,"maximum":70.910,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":58.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":66.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":58.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":70.910,"methodology":"fee schedule"}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC ","code_information":[{"code":"054","type":"MS-DRG"},{"code":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":12450.970,"maximum":12450.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12450.970,"methodology":"fee schedule"}]}]},{"description":"Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation ","code_information":[{"code":"361","type":"RC"},{"code":"47490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) ","code_information":[{"code":"45342","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization ","code_information":[{"code":"61595","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, vibration) elastography ","code_information":[{"code":"323","type":"RC"},{"code":"76391","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":67.840,"maximum":82.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":67.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":76.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":67.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":82.500,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, nasal bones, complete, minimum of 3 views ","code_information":[{"code":"618","type":"RC"},{"code":"70160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with parietal pleurectomy ","code_information":[{"code":"32656","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3673.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":3050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3637.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2808.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes obtaining bone graft when performed, unilateral; placement of intra-articular device(s), without cortic ","code_information":[{"code":"27278","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"515","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24284.730,"maximum":24284.730,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":24284.730,"methodology":"fee schedule"}]}]},{"description":"Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during ","code_information":[{"code":"37213","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8911.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":6716.890,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8911.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":8400.000,"methodology":"case rate"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":6853.970,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":6579.810,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":6716.890,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":6853.970,"methodology":"fee schedule"}]}]},{"description":"Cholecystectomy with exploration of common duct; with choledochoenterostomy ","code_information":[{"code":"47612","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"}]}]},{"description":"Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell ","code_information":[{"code":"312","type":"RC"},{"code":"86885","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.720,"maximum":6.750,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.720,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.750,"methodology":"fee schedule"}]}]},{"description":"Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation) ","code_information":[{"code":"61343","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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; tibia and fibula, 2 views ","code_information":[{"code":"73590","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.420,"maximum":44.420,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":44.420,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":44.420,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":44.420,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":44.420,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":44.420,"methodology":"fee schedule"}]}]},{"description":"Replacement, tricuspid valve, with cardiopulmonary bypass ","code_information":[{"code":"33465","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12724.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"}]}]},{"description":"Excision of local lesion of epididymis ","code_information":[{"code":"360","type":"RC"},{"code":"54830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separat ","code_information":[{"code":"323","type":"RC"},{"code":"76814","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.270,"maximum":85.200,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":57.270,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":85.200,"methodology":"fee schedule"}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC ","code_information":[{"code":"075","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15235.480,"maximum":15235.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15235.480,"methodology":"fee schedule"}]}]},{"description":"Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane ","code_information":[{"code":"33732","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION ","code_information":[{"code":"136","type":"RC"},{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":49232.560,"maximum":49232.560,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":49232.560,"methodology":"fee schedule"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"157","type":"RC"},{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8433.200,"maximum":8433.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8433.200,"methodology":"fee schedule"}]}]},{"description":"Sternal debridement ","code_information":[{"code":"21627","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection of pre-exposure prophylaxis (prep) drug for hiv prevention, under skin or into muscle ","code_information":[{"code":"G0012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":178.970,"maximum":186.430,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":182.700,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":186.430,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":178.970,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":182.700,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":186.430,"methodology":"fee schedule"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC ","code_information":[{"code":"219","type":"RC"},{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12254.940,"maximum":12254.940,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12254.940,"methodology":"fee schedule"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants ","code_information":[{"code":"306","type":"RC"},{"code":"81221","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.900,"maximum":114.720,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":90.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":106.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":90.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":106.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":97.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":114.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":97.220,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"716","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12052.480,"maximum":12052.480,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12052.480,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; complex ","code_information":[{"code":"409","type":"RC"},{"code":"77763","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":619.860,"maximum":753.850,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":619.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":703.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":619.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":753.850,"methodology":"fee schedule"}]}]},{"description":"Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiol ","code_information":[{"code":"50433","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (solid tumor as indicated by the label), somatic mutation analyis of BRCA1, BRCA2 and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, a ","code_information":[{"code":"0172U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3030.000,"maximum":3575.400,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3030.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3575.400,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF FEMUR WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12741.830,"maximum":12741.830,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12741.830,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) ","code_information":[{"code":"43265","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination from nose to rectum for foreign body, single view, child ","code_information":[{"code":"614","type":"RC"},{"code":"76010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy ","code_information":[{"code":"481","type":"RC"},{"code":"57250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography ","code_information":[{"code":"402","type":"RC"},{"code":"78630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":611.490,"maximum":635.160,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":611.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"Osteotomy and transfer of greater trochanter of femur (separate procedure) ","code_information":[{"code":"27140","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Adenoidectomy, secondary; younger than age 12 ","code_information":[{"code":"42835","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Open treatment of acute or chronic elbow dislocation ","code_information":[{"code":"24615","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional 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); thoracic ","code_information":[{"code":"22206","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of metatarsophalangeal joint dislocation; without anesthesia ","code_information":[{"code":"28630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":603.240,"maximum":4950.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":615.800,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":628.370,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":603.240,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":615.800,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":628.370,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"164","type":"RC"},{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8947.180,"maximum":8947.180,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8947.180,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm ","code_information":[{"code":"11602","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC Pediatric","code_information":[{"code":"728","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12739.080,"maximum":17834.230,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":17834.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":17834.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":17834.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":17834.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":12739.080,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL ","code_information":[{"code":"114","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15583.360,"maximum":15583.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":15583.360,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9712.100,"maximum":9712.100,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9712.100,"methodology":"fee schedule"}]}]},{"description":"Creation of arteriovenous fistula, percutaneous using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization wit ","code_information":[{"code":"790","type":"RC"},{"code":"C9755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":12275.200,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"}]}]},{"description":"Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach ","code_information":[{"code":"369","type":"RC"},{"code":"58140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":10668.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Excision of urethral diverticulum (separate procedure); female ","code_information":[{"code":"53230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":11798.460,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":11562.490,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":11798.460,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":11326.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":11562.490,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":11798.460,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5444.110,"maximum":5444.110,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":5444.110,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus) ","code_information":[{"code":"311","type":"RC"},{"code":"87633","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":491.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":491.800,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, ureter ","code_information":[{"code":"361","type":"RC"},{"code":"50949","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures ","code_information":[{"code":"367","type":"RC"},{"code":"43237","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALTERATION IN CONSCIOUSNESS ","code_information":[{"code":"0521","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3877.650,"maximum":5816.480,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":3877.650,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":3955.200,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":5816.480,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":3877.650,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":3877.650,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":3877.650,"methodology":"fee schedule"}]}]},{"description":"Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed; for aortic disease other than dissection (eg, aneurysm) ","code_information":[{"code":"33859","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Enterolysis (freeing of intestinal adhesion) (separate procedure) ","code_information":[{"code":"44005","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area ","code_information":[{"code":"69727","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization ","code_information":[{"code":"480","type":"RC"},{"code":"65450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"Excision of carotid body tumor; without excision of carotid artery ","code_information":[{"code":"60600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant ","code_information":[{"code":"28289","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10138.400,"maximum":10138.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":10138.400,"methodology":"fee schedule"}]}]},{"description":"Carbohydrate deficient transferrin ","code_information":[{"code":"304","type":"RC"},{"code":"82373","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.890,"maximum":21.310,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.870,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.060,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.060,"methodology":"fee schedule"}]}]},{"description":"Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0268U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":568.640,"maximum":717.640,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":568.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":668.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":568.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":668.990,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":717.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":608.170,"methodology":"fee schedule"}]}]},{"description":"Transluminal dilation of aqueous outflow canal (eg, canaloplasty); with retention of device or stent ","code_information":[{"code":"480","type":"RC"},{"code":"66175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with control of traumatic hemorrhage ","code_information":[{"code":"32654","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":11066.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"}]}]},{"description":"INCISION AND DRAINAGE OF SOFT TISSUE ABSCESS, SUBFASCIAL (IE, INVOLVES THE SOFT TISSUE BELOW THE DEEP FASCIA) ","code_information":[{"code":"20005","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHE ","code_information":[{"code":"041","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":17240.080,"maximum":17240.080,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":17240.080,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3811.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1193.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3811.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $280800.00, reimbursement will be $5150 per diem instead of the contracted rate."}]}]},{"description":"Mechanical fragility, RBC, shear stress and spectral analysis profiling ","code_information":[{"code":"0123U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":357.630,"maximum":422.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":357.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":422.000,"methodology":"fee schedule"}]}]},{"description":"Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibula ","code_information":[{"code":"27832","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) ","code_information":[{"code":"21240","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Duograft aa, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.350,"maximum":273.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":273.350,"methodology":"fee schedule"}]}]},{"description":"TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) ","code_information":[{"code":"310","type":"RC"},{"code":"81342","type":"CPT"},{"code":"818180","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":201.500,"maximum":237.770,"gross_charge":961.75,"discounted_cash":961.75,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":201.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":237.770,"methodology":"fee schedule"}]}]},{"description":"Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) ","code_information":[{"code":"45120","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":7682.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), including all radiological supervision and interpretation, int ","code_information":[{"code":"61624","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"PENIS PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11554.880,"maximum":11554.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11554.880,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoro ","code_information":[{"code":"33962","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) ","code_information":[{"code":"20552","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy ","code_information":[{"code":"29900","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Viscosity ","code_information":[{"code":"85810","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10.910,"maximum":13.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.840,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.770,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.670,"methodology":"fee schedule"}]}]},{"description":"Injection, denosumab, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0897","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":63.340,"maximum":63.340,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":63.340,"methodology":"fee schedule"}]}]},{"description":"Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, each ","code_information":[{"code":"28525","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"121","type":"RC"},{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26938.770,"maximum":26938.770,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26938.770,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11495.720,"maximum":11495.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11495.720,"methodology":"fee schedule"}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC ","code_information":[{"code":"137","type":"RC"},{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35504.700,"maximum":35504.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":35504.700,"methodology":"fee schedule"}]}]},{"description":"TESTES PROCEDURES WITH CC/MCC ","code_information":[{"code":"174","type":"RC"},{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16420.980,"maximum":16420.980,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16420.980,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, maternity care and delivery ","code_information":[{"code":"367","type":"RC"},{"code":"59898","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum ","code_information":[{"code":"43647","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Krukenberg procedure ","code_information":[{"code":"25915","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Myelography, thoracic, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"72255","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":57.010,"maximum":69.340,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":57.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":64.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":57.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":69.340,"methodology":"fee schedule"}]}]},{"description":"Injection, octafluoropropane microspheres, per ml ","drug_information":{"unit":3.000000000000000e+000,"type":"ML"},"code_information":[{"code":"636","type":"RC"},{"code":"640131","type":"CDM"},{"code":"Q9956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":86.450,"maximum":86.450,"gross_charge":512.50,"discounted_cash":512.50,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":86.450,"methodology":"fee schedule"}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26706.370,"maximum":26706.370,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":26706.370,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation ","code_information":[{"code":"611","type":"RC"},{"code":"76801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.480,"maximum":125.480,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.480,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"213","type":"RC"},{"code":"816","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6071.440,"maximum":6071.440,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6071.440,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC ","code_information":[{"code":"201","type":"RC"},{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18144.010,"maximum":18144.010,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":18144.010,"methodology":"fee schedule"}]}]},{"description":"Chloride; urine ","code_information":[{"code":"304","type":"RC"},{"code":"82436","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.380,"maximum":6.780,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.330,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.750,"methodology":"fee schedule"}]}]},{"description":"Cystography, minimum of 3 views, radiological supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"74430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.280,"maximum":421.410,"payers_information":[{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":42.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":421.410,"methodology":"fee schedule"}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12788.880,"maximum":12788.880,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12788.880,"methodology":"fee schedule"}]}]},{"description":"Brachytherapy isodose plan; complex (calculationºs» made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) ","code_information":[{"code":"610","type":"RC"},{"code":"77318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":431.960,"maximum":431.960,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":431.960,"methodology":"fee schedule"}]}]},{"description":"Manipulation, elbow, under anesthesia ","code_information":[{"code":"24300","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES ","code_information":[{"code":"127","type":"RC"},{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":42249.220,"maximum":42249.220,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":42249.220,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine (liver allograft rejection), miRNA gene expression profiling by RT-PCR of 4 genes (miR-122, miR-885, miR-23a housekeeping, spike-in control), ","code_information":[{"code":"0575U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":355.300,"maximum":448.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":355.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":418.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":355.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":418.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":380.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":448.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":380.000,"methodology":"fee schedule"}]}]},{"description":"Catheterization for collection of specimen(s) (multiple patients) ","code_information":[{"code":"312","type":"RC"},{"code":"P9615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":9.340,"maximum":11.020,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.340,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.020,"methodology":"fee schedule"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; each additional 480 sq cm or part thereof (List separately in addi ","code_information":[{"code":"15016","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tracheoplasty; intrathoracic ","code_information":[{"code":"31760","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3348.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of mandibular fracture; without manipulation ","code_information":[{"code":"21450","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study ","code_information":[{"code":"329","type":"RC"},{"code":"74230","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":135.400,"maximum":164.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":135.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":153.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":135.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":164.660,"methodology":"fee schedule"}]}]},{"description":"Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) ","code_information":[{"code":"38770","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11066.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22568.120,"maximum":22568.120,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22568.120,"methodology":"fee schedule"}]}]},{"description":"Bypass graft; composite, prosthetic and vein (List separately in addition to code for primary procedure) ","code_information":[{"code":"35681","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tyrosinemia typr I monitoring by patient-collected blood card sample, quantitative measurement of tyrosine, phenylalanine, methionine, succinylacetone, nitisinone, liquid chromatography with tandem ma ","code_information":[{"code":"0383U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":48.670,"maximum":61.420,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":48.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":57.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":48.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":57.260,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":61.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":52.050,"methodology":"fee schedule"}]}]},{"description":"FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence ","code_information":[{"code":"319","type":"RC"},{"code":"81286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":274.830,"maximum":324.300,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":324.300,"methodology":"fee schedule"}]}]},{"description":"Sesamoidectomy, thumb or finger (separate procedure) ","code_information":[{"code":"26185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4182.220,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4098.580,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":4182.220,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4014.930,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":4098.580,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":4182.220,"methodology":"fee schedule"}]}]},{"description":"Breast reduction ","code_information":[{"code":"19318","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11888.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"CERVICAL SPINAL FUSION WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35988.740,"maximum":35988.740,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":35988.740,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing t ","code_information":[{"code":"369","type":"RC"},{"code":"37297","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1637.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA ","code_information":[{"code":"117","type":"RC"},{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28391.610,"maximum":28391.610,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":28391.610,"methodology":"fee schedule"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC ","code_information":[{"code":"209","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13559.500,"maximum":13559.500,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13559.500,"methodology":"fee schedule"}]}]},{"description":"Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21 ","code_information":[{"code":"81420","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":709.710,"maximum":895.680,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":709.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":834.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":709.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":834.960,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":895.680,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":759.050,"methodology":"fee schedule"}]}]},{"description":"Oncology, disease progression and response monitoring to radiation, chemotherapy, or other systemic cancer treatments, cell-free DNA, quantitative branced chain DNA amplification, plasma, reporting ","code_information":[{"code":"0285U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":414.490,"maximum":523.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":414.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":487.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":414.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":487.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":523.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":443.310,"methodology":"fee schedule"}]}]},{"description":"Bone marrow imaging; whole body ","code_information":[{"code":"341","type":"RC"},{"code":"78104","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":48.390,"maximum":55.780,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":48.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":54.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":48.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":55.780,"methodology":"fee schedule"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16430.970,"maximum":16430.970,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":16430.970,"methodology":"fee schedule"}]}]},{"description":"Hydroxyindolacetic acid, 5-(HIAA) ","code_information":[{"code":"311","type":"RC"},{"code":"83497","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.900,"maximum":15.220,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.220,"methodology":"fee schedule"}]}]},{"description":"Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and child ","code_information":[{"code":"15116","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Oncology (solid tumor), cell-free DNA and RNA by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and tumor-derived single-nuc ","code_information":[{"code":"0485U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3412.260,"maximum":4306.390,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3412.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4014.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3412.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4014.430,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3649.480,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4306.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.480,"methodology":"fee schedule"}]}]},{"description":"KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) ","code_information":[{"code":"319","type":"RC"},{"code":"81276","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.250,"maximum":228.030,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":228.030,"methodology":"fee schedule"}]}]},{"description":"Oncology (diffuse large B-cell lymphoma ºDLBCL»), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of ","code_information":[{"code":"0017M","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2347.050,"maximum":2962.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2347.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2761.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2347.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2761.230,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2510.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2962.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2510.210,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) ","code_information":[{"code":"43275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":4950.000,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":4400.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4353.590,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":4442.440,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4264.740,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":4353.590,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":4442.440,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) ","code_information":[{"code":"J0129","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":42.080,"maximum":114.730,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"OpenAccess","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"POS","standard_charge_percentage":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":34.40,"standard_charge_algorithm":"Reimbursement will be 34.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"QualifiedHealthPlan","standard_charge_percentage":25.86,"standard_charge_algorithm":"Reimbursement will be 25.86% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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 Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":50.700,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":50.780,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":74.670,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":112.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":42.080,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":114.730,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":49.780,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":110.140,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":112.440,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":114.730,"methodology":"fee schedule"}]}]},{"description":"Repair, diaphragmatic hernia (other than neonatal), traumatic; acute ","code_information":[{"code":"39540","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D198Z9","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3296.000,"maximum":3296.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3296.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Correction of trichiasis; epilation, by forceps only ","code_information":[{"code":"480","type":"RC"},{"code":"67820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"138","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2418.470,"maximum":2941.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2743.490,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2418.470,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2941.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":2837.900,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Cryopreservation; sperm ","code_information":[{"code":"89259","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":139.460,"maximum":164.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":139.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":164.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":139.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":164.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, head or brain; with contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"70460","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":136.210,"maximum":165.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":136.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":154.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":136.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":165.650,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Borrelia miyamotoi, amplified probe technique ","code_information":[{"code":"304","type":"RC"},{"code":"87478","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.810,"maximum":41.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including mastoidectomy, resect ","code_information":[{"code":"499","type":"RC"},{"code":"61591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":12326.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11495.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10133.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12326.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11891.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC ","code_information":[{"code":"053","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8546.550,"maximum":8546.550,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":8546.550,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC ","code_information":[{"code":"021","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":39304.330,"maximum":39304.330,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":39304.330,"methodology":"fee schedule"}]}]},{"description":"Gastroenterology (irritable bowel syndrome), IgG antibodies to 18 food items by microarray-based immunoassay, whole blood or serum, report as elevated ","code_information":[{"code":"0598U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":280.500,"maximum":354.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":280.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":330.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":280.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":330.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":354.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":300.000,"methodology":"fee schedule"}]}]},{"description":"Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed ","code_information":[{"code":"33477","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11888.700,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":2205.000,"methodology":"case rate"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11087.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9773.710,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11888.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":11468.800,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4178.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft ","code_information":[{"code":"21143","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":10668.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9948.790,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8770.160,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10668.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10291.200,"methodology":"case rate"}]}]},{"description":"Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1 ","code_information":[{"code":"304","type":"RC"},{"code":"81419","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2289.400,"maximum":2889.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2289.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2693.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2289.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2693.420,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2448.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2889.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2448.560,"methodology":"fee schedule"}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7772.360,"maximum":7772.360,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7772.360,"methodology":"fee schedule"}]}]},{"description":"Repair blood vessel, direct; upper extremity ","code_information":[{"code":"35206","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2108.000,"maximum":7992.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2755.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2289.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2729.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2108.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7992.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of femoral fracture, proximal end, neck; without manipulation ","code_information":[{"code":"27230","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7027.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1496.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1285.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1482.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4532.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":4532.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":4532.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":4532.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":4532.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":3273.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2942.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":2206.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":2942.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2942.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1424.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1349.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":967.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra ","code_information":[{"code":"481","type":"RC"},{"code":"54300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2284.000,"maximum":11616.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7411.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2986.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2481.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2958.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2284.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11616.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, trachea, bronchi ","code_information":[{"code":"31899","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":12724.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11866.800,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10460.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12724.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":12275.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1637.000,"methodology":"case rate"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; intermediate ","code_information":[{"code":"324","type":"RC"},{"code":"77285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":431.960,"maximum":777.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":639.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":725.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":639.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":777.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":431.960,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique ","code_information":[{"code":"87556","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.700,"maximum":62.520,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":37.510,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":42.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":37.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":37.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":37.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":37.510,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":43.760,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":42.930,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":43.760,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":61.100,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":62.520,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":43.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":43.760,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":40.430,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":50.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":42.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":42.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":42.100,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":35.700,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":62.520,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":43.760,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":41.680,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":42.510,"methodology":"fee schedule"}]}]},{"description":"Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse ","code_information":[{"code":"0916T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":33480.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24779.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21843.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26570.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33480.000,"methodology":"case rate"}]}]},{"description":"Transvesical ureterolithotomy ","code_information":[{"code":"51060","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) ","code_information":[{"code":"403","type":"RC"},{"code":"78709","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":635.160,"maximum":635.160,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":635.160,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6720.870,"maximum":6720.870,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6720.870,"methodology":"fee schedule"}]}]},{"description":"Aspiration and/or injection of ganglion cyst(s) any location ","code_information":[{"code":"20612","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intrinsic muscles of hand, each muscle ","code_information":[{"code":"26591","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11859.290,"maximum":11859.290,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11859.290,"methodology":"fee schedule"}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC ","code_information":[{"code":"173","type":"RC"},{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20528.580,"maximum":20528.580,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":20528.580,"methodology":"fee schedule"}]}]},{"description":"Culture, chlamydia, any source ","code_information":[{"code":"87110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.780,"maximum":34.110,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":17.640,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":19.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":17.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":17.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":17.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":17.640,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":20.580,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":20.190,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":19.990,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20.580,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":34.110,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":19.990,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":20.580,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20.580,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":19.010,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":23.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19.800,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":16.780,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":29.400,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20.580,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":19.600,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":19.990,"methodology":"fee schedule"}]}]},{"description":"Periodontal mucosal grafting ","code_information":[{"code":"41870","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Thyrotropin releasing hormone (TRH) stimulation panel; 1 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3) ","code_information":[{"code":"304","type":"RC"},{"code":"80438","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.130,"maximum":59.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":47.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":55.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":47.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":55.450,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":50.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":59.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":50.410,"methodology":"fee schedule"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11035.200,"maximum":11035.200,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11035.200,"methodology":"fee schedule"}]}]},{"description":"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27740.040,"maximum":27740.040,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":27740.040,"methodology":"fee schedule"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22327.170,"maximum":22327.170,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":22327.170,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique ","code_information":[{"code":"44394","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":1898.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1615.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":1880.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1488.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) ","code_information":[{"code":"54700","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"New Technology - Level 4 ","code_information":[{"code":"1504","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":213.050,"maximum":329.470,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":221.840,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":226.230,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":230.630,"methodology":"fee schedule"},{"payer_name":"Coventry","plan_name":"MGMCR","standard_charge_dollar":224.040,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":219.640,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":230.630,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":230.630,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":213.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":221.840,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":221.840,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":221.840,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCD","standard_charge_dollar":219.640,"methodology":"fee schedule"},{"payer_name":"Hospice Care Options","plan_name":"MCR","standard_charge_dollar":219.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":219.640,"methodology":"fee schedule"},{"payer_name":"Ryan White CARE Act","plan_name":"LOGOV","standard_charge_dollar":329.470,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":230.630,"methodology":"fee schedule"},{"payer_name":"Southern Care Birmingham","plan_name":"COMM","standard_charge_dollar":219.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":224.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":219.640,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":224.040,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited ","code_information":[{"code":"618","type":"RC"},{"code":"76642","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.900,"maximum":103.900,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":103.900,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6939.720,"maximum":6939.720,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6939.720,"methodology":"fee schedule"}]}]},{"description":"Surgical closure tracheostomy or fistula; with plastic repair ","code_information":[{"code":"31825","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":4299.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session from insertion ","code_information":[{"code":"33997","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma ","code_information":[{"code":"362","type":"RC"},{"code":"61510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"039","type":"MS-DRG"},{"code":"151","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":9945.920,"maximum":9945.920,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":9945.920,"methodology":"fee schedule"}]}]},{"description":"RECTAL RESECTION WITHOUT CC/MCC ","code_information":[{"code":"200","type":"RC"},{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13242.270,"maximum":13242.270,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":13242.270,"methodology":"fee schedule"}]}]},{"description":"Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method ","code_information":[{"code":"30901","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":324.140,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":330.900,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":337.650,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":324.140,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":330.900,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":337.650,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"160","type":"RC"},{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12294.850,"maximum":12294.850,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":12294.850,"methodology":"fee schedule"}]}]},{"description":"Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) ","code_information":[{"code":"321","type":"RC"},{"code":"77063","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":37.590,"maximum":45.710,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.710,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC ","code_information":[{"code":"083","type":"MS-DRG"},{"code":"212","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11516.400,"maximum":11516.400,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11516.400,"methodology":"fee schedule"}]}]},{"description":"Tubouterine implantation ","code_information":[{"code":"367","type":"RC"},{"code":"58752","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6422.890,"maximum":6422.890,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":6422.890,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple ","code_information":[{"code":"38570","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2635.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10320.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9097.420,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":10675.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":3446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":2863.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":3414.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":2635.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"ORBITAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"114","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11211.280,"maximum":11211.280,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":11211.280,"methodology":"fee schedule"}]}]},{"description":"Shunt; descending aorta to pulmonary artery (Potts-Smith type operation) ","code_information":[{"code":"33762","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":9.92,"standard_charge_algorithm":"Reimbursement will be 9.92% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_percentage":14.60,"standard_charge_algorithm":"Reimbursement will be 14.6% 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":"Laurens County Jail","plan_name":"COMM","standard_charge_percentage":9.73,"standard_charge_algorithm":"Reimbursement will be 9.73% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Aortography, abdominal, by serialography, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75625","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":87.450,"maximum":106.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":87.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":99.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":87.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":106.350,"methodology":"fee schedule"}]}]},{"description":"RHEUMATOID, OTHER ARTHRITIS; M > 26.15 & M < 36.35 ","code_information":[{"code":"128","type":"RC"},{"code":"D1302","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17590.810,"maximum":20129.690,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":19222.950,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":18134.860,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":20129.690,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":19041.600,"methodology":"fee schedule"},{"payer_name":"Health Net","plan_name":"FED","standard_charge_dollar":17590.810,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18316.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":18316.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":18316.210,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":18134.860,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":20129.690,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":20129.690,"methodology":"fee schedule"}]}]},{"description":"Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration ","code_information":[{"code":"38227","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3224.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6793.390,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5988.600,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7284.450,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3348.000,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"201","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7043.090,"maximum":7043.090,"payers_information":[{"payer_name":"Americas 1st Choice","plan_name":"MCR","standard_charge_dollar":7043.090,"methodology":"fee schedule"}]}]},{"description":"Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach ","code_information":[{"code":"45190","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6917.130,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6097.670,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7417.150,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":7155.200,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COASTALHEALTHPLAN","standard_charge_dollar":2297.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"COMM","standard_charge_dollar":1909.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"CORECOMMUNITYCARE","standard_charge_dollar":2276.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Memorial Health Plan","plan_name":"HEALTHGRAM","standard_charge_dollar":1758.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5400.000,"methodology":"case rate"}]}]},{"description":"Urography, infusion, drip technique and/or bolus technique; ","code_information":[{"code":"322","type":"RC"},{"code":"74410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":154.850,"maximum":401.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":203.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":230.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":203.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":247.550,"methodology":"fee schedule"},{"payer_name":"Core Resources","plan_name":"COMM","standard_charge_dollar":166.340,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":154.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":210.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Vitamin A ","code_information":[{"code":"305","type":"RC"},{"code":"84590","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.860,"maximum":13.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.770,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.610,"methodology":"fee schedule"}]}]},{"description":"Pathology clinical consultation; for a clinical problem, with limited review of patient's history and medical records and straightforward medical decision making When using time for code selection, 5- ","code_information":[{"code":"80503","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.070,"maximum":139.960,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":24.220,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":23.530,"methodology":"fee schedule"},{"payer_name":"Dept of Community Health","plan_name":"COMM","standard_charge_dollar":34.610,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":137.160,"methodology":"fee schedule"},{"payer_name":"Identity MCO ","plan_name":"WorkersComp","standard_charge_dollar":139.960,"methodology":"fee schedule"},{"payer_name":"Laurens County Jail","plan_name":"COMM","standard_charge_dollar":23.070,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":134.360,"methodology":"fee schedule"},{"payer_name":"Rockport United Network","plan_name":"WORKERSCOMP","standard_charge_dollar":137.160,"methodology":"fee schedule"},{"payer_name":"Synergy Health Network","plan_name":"WorkersComp","standard_charge_dollar":139.960,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation ","code_information":[{"code":"28576","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1758.000,"maximum":7682.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7164.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6315.830,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7682.510,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4299.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"LocalPlus","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multi