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For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","confirm_attestation":true,"attester_name":"Mitch Edgeworth"},"standard_charge_information":[{"description":"Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for primary procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"64913","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"174","type":"RC"},{"code":"724","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7037.790,"maximum":8434.180,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":7037.790,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":8434.180,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC ","code_information":[{"code":"097","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":31619.210,"maximum":37892.860,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":31619.210,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":37892.860,"methodology":"fee schedule"}]}]},{"description":"Osteotomy; 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PROCEDURES WITH MCC ","code_information":[{"code":"143","type":"MS-DRG"},{"code":"174","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":28912.770,"maximum":34649.430,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":28912.770,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":34649.430,"methodology":"fee schedule"}]}]},{"description":"Excision, olecranon bursa ","code_information":[{"code":"24105","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1011.790,"maximum":1031.820,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1011.790,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1011.790,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1011.790,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1031.820,"methodology":"fee schedule","additional_payer_notes":"Days 10+. 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","code_information":[{"code":"367","type":"RC"},{"code":"50980","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"IV US FIRST VESSEL ADD-ON 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older ","code_information":[{"code":"361","type":"RC"},{"code":"36561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm ","code_information":[{"code":"17284","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesionºs») ","code_information":[{"code":"21047","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"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"}],"standard_charges":[{"setting":"outpatient","minimum":260.500,"maximum":375.120,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":263.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":263.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":263.110,"methodology":"fee 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procedure logic."}]}]},{"description":"Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation ","code_information":[{"code":"26645","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Removal of peritoneal foreign body from peritoneal cavity ","code_information":[{"code":"49402","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic 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","code_information":[{"code":"27465","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) ","code_information":[{"code":"22226","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction ","code_information":[{"code":"480","type":"RC"},{"code":"65265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case 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logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Incision and drainage, complex, postoperative wound infection ","code_information":[{"code":"10180","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright 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Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm ","code_information":[{"code":"17262","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Ultrasonic guidance for amniocentesis, imaging supervision and interpretation ","code_information":[{"code":"76946","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.640,"maximum":44.640,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":44.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":44.640,"methodology":"fee schedule"}]}]},{"description":"Factor ix idelvion inj ","code_information":[{"code":"9171","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":5.320,"maximum":7.650,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":5.370,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":5.370,"methodology":"fee 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":918.810,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":918.810,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":937.010,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated evaluations by a physician or other qualified h ","code_information":[{"code":"841","type":"RC"},{"code":"90947","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_percentage":34.00,"standard_charge_algorithm":"Reimbursement will be 34% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and moni ","code_information":[{"code":"360","type":"RC"},{"code":"36482","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm ","code_information":[{"code":"11622","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6138.830,"maximum":7356.860,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6138.830,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7356.860,"methodology":"fee schedule"}]}]},{"description":"Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger ","code_information":[{"code":"26426","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for decompression ","code_information":[{"code":"369","type":"RC"},{"code":"67414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array ","code_information":[{"code":"361","type":"RC"},{"code":"64596","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC ","code_information":[{"code":"021","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":131423.880,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":131423.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":105902.470,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":51612.330,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":61856.180,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":91423.930,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens ","code_information":[{"code":"0616T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including ","code_information":[{"code":"38573","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"Episiotomy or vaginal repair, by other than attending ","code_information":[{"code":"367","type":"RC"},{"code":"59300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"HExtracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound ","code_information":[{"code":"0299T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure) ","code_information":[{"code":"11732","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12636.730,"maximum":15144.020,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12636.730,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":15144.020,"methodology":"fee schedule"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC ","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":38107.910,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":38107.910,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":30707.670,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12575.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":15071.740,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":26509.450,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; ","code_information":[{"code":"26210","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of humeral shaft fracture; without manipulation ","code_information":[{"code":"24500","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright 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","code_information":[{"code":"361","type":"RC"},{"code":"62303","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Removal of tunneled central venous catheter, without subcutaneous port or pump 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","code_information":[{"code":"361","type":"RC"},{"code":"43757","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) ","code_information":[{"code":"21348","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  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augmentation (autograft, allograft, prosthetic material) ","code_information":[{"code":"21120","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE ","code_information":[{"code":"123","type":"RC"},{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":49240.210,"maximum":59010.090,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":49240.210,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":59010.090,"methodology":"fee schedule"}]}]},{"description":"Manipulation, hip joint, requiring general anesthesia ","code_information":[{"code":"27275","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 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histoplasma ","code_information":[{"code":"86698","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.960,"maximum":19.860,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10.960,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":10.960,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":15.860,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":13.790,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":19.860,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":14.200,"methodology":"fee schedule"}]}]},{"description":"Pulmonary Treatment ","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":210.080,"maximum":302.520,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":212.180,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":212.180,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":212.180,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":241.590,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":210.080,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":302.520,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":216.380,"methodology":"fee schedule"}]}]},{"description":"Removal of implant; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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with shunt ","code_information":[{"code":"362","type":"RC"},{"code":"69806","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues ","code_information":[{"code":"362","type":"RC"},{"code":"42810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"179","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6164.920,"maximum":7388.110,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6164.920,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7388.110,"methodology":"fee schedule"}]}]},{"description":"Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed ","code_information":[{"code":"28615","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, arterial system; 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further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, de ","code_information":[{"code":"97597","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":93.960,"maximum":135.300,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":94.900,"methodology":"fee 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may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve ","code_information":[{"code":"480","type":"RC"},{"code":"64910","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"361","type":"RC"},{"code":"49082","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"15828","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body 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","code_information":[{"code":"46945","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Biopsy, soft tissue of thigh or knee area; superficial 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epidural, cervical or thoracic ","code_information":[{"code":"361","type":"RC"},{"code":"62281","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, leg; posterior compartment(s) only ","code_information":[{"code":"27601","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of radial shaft fracture; 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with ultrasound guidance, with permanent re ","code_information":[{"code":"20606","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance ","code_information":[{"code":"32557","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Reconstruction, toe, macrodactyly; requiring bone resection ","code_information":[{"code":"28341","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulorrhaphy, anterior, any type; with coracoid process transfer ","code_information":[{"code":"23462","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Excision of urethral diverticulum (separate procedure); male ","code_information":[{"code":"362","type":"RC"},{"code":"53235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision or fulguration of carcinoma of urethra ","code_information":[{"code":"360","type":"RC"},{"code":"53220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Excision of thyroglossal duct cyst or sinus; recurrent ","code_information":[{"code":"360","type":"RC"},{"code":"60281","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction ","code_information":[{"code":"27752","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Drainage of palmar bursa; single, bursa ","code_information":[{"code":"26025","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8688.780,"maximum":10412.750,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":8688.780,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":10412.750,"methodology":"fee schedule"}]}]},{"description":"Venipuncture, cutdown; younger than age 1 year ","code_information":[{"code":"36420","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10330.210,"maximum":12379.860,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":10330.210,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":12379.860,"methodology":"fee schedule"}]}]},{"description":"Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed ","code_information":[{"code":"369","type":"RC"},{"code":"64473","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler type) ","code_information":[{"code":"28305","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings) ","code_information":[{"code":"0748T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) ","code_information":[{"code":"360","type":"RC"},{"code":"43232","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; 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","code_information":[{"code":"15820","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Gamma globulin > 10 cc in ","code_information":[{"code":"1851","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":104.520,"maximum":150.510,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":105.570,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":105.570,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":105.570,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":120.200,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":104.520,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":150.510,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":107.660,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC  IPF","code_information":[{"code":"056","type":"MS-DRG"},{"code":"204","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1225.080,"maximum":1249.340,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1225.080,"methodology":"fee schedule","additional_payer_notes":"Days 2. 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"}]}]},{"description":"CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT MANIPULATION ","code_information":[{"code":"21310","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"SCLERAL FISTULIZATION ","code_information":[{"code":"0123T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each ","code_information":[{"code":"26727","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITH CC ","code_information":[{"code":"172","type":"RC"},{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8661.830,"maximum":10380.450,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":8661.830,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":10380.450,"methodology":"fee schedule"}]}]},{"description":"AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC ","code_information":[{"code":"016","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":53702.840,"maximum":64358.160,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":53702.840,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":64358.160,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of ankle dislocation; 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logic."}]}]},{"description":"Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guidance ","code_information":[{"code":"33019","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14137.000,"maximum":16577.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":16577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NAP","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. 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"}]}]},{"description":"Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); ","code_information":[{"code":"27496","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance ","code_information":[{"code":"360","type":"RC"},{"code":"43236","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Cystotomy; for simple excision of vesical neck (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"51520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"CHANGE KIDNEY TUBE ","code_information":[{"code":"361","type":"RC"},{"code":"50398","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fasciotomy, foot and/or toe ","code_information":[{"code":"28008","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Injection, anesthetic agent; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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removal of subcutaneous port component only ","code_information":[{"code":"367","type":"RC"},{"code":"43887","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"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":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Transmetacarpal amputation; secondary closure or scar revision ","code_information":[{"code":"25929","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, ankle; with implant (total ankle) ","code_information":[{"code":"27702","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less ","code_information":[{"code":"12051","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Repositioning of previously implanted subcutaneous implantable defibrillator electrode ","code_information":[{"code":"33273","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion, sclera ","code_information":[{"code":"480","type":"RC"},{"code":"66130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC  IPF","code_information":[{"code":"154","type":"RC"},{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1039.130,"maximum":1059.710,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1039.130,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1039.130,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1039.130,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1059.710,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Osteotomy, femur, shaft or supracondylar; with fixation ","code_information":[{"code":"27450","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion, conjunctiva; up to 1 cm ","code_information":[{"code":"361","type":"RC"},{"code":"68110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Reconstruction external auditory canal for congenital atresia, single stage ","code_information":[{"code":"481","type":"RC"},{"code":"69320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Mastotomy with exploration or drainage of abscess, deep ","code_information":[{"code":"19020","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC ","code_information":[{"code":"258","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":78005.770,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":78005.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":62857.710,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":22763.070,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":27281.020,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"367","type":"RC"},{"code":"42107","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendon 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":31196.530,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level (List separately in a ","code_information":[{"code":"0630T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"19298","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"Oncology (solid tumor), mass spectrometric 30 protein targets, formalin-fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as 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","code_information":[{"code":"21432","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar ","code_information":[{"code":"22865","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case 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","code_information":[{"code":"31520","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC 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multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11273.510,"maximum":13510.320,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11273.510,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13510.320,"methodology":"fee schedule"}]}]},{"description":"KIDNEY TRANSPLANT ","code_information":[{"code":"172","type":"RC"},{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26120.250,"maximum":31302.840,"payers_information":[{"payer_name":"Bright 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1194.450,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1194.450,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1218.110,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"172","type":"RC"},{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7269.920,"maximum":8712.370,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":7269.920,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":8712.370,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays ","code_information":[{"code":"481","type":"RC"},{"code":"61886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Gonadotropin, chorionic (hCG); free beta chain ","code_information":[{"code":"84704","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.160,"maximum":22.020,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":12.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":15.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":15.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":15.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":12.160,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":17.580,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":15.290,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":22.020,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":15.750,"methodology":"fee schedule"}]}]},{"description":"Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation ","code_information":[{"code":"76932","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":123.380,"maximum":123.380,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":123.380,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":123.380,"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":"367","type":"RC"},{"code":"40761","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Orbitotomy without bone flap (frontal or transconjunctival approach); 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first 480 sq cm or less ","code_information":[{"code":"15015","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Donor hysterectomy (including cold preservation); open, from living donor ","code_information":[{"code":"0665T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"171","type":"RC"},{"code":"425","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13926.920,"maximum":16690.200,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13926.920,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16690.200,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of leg or ankle area; superficial ","code_information":[{"code":"27613","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed ","code_information":[{"code":"28645","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"231","type":"RC"},{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8615.750,"maximum":10325.230,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":8615.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":10325.230,"methodology":"fee schedule"}]}]},{"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; 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":886.000,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":886.000,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":903.540,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"ACTH stimulation panel; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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chronic ","code_information":[{"code":"23412","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"RED BLOOD CELL DISORDERS WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12202.900,"maximum":14624.110,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12202.900,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14624.110,"methodology":"fee schedule"}]}]},{"description":"Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session ","code_information":[{"code":"361","type":"RC"},{"code":"53447","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 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with anesthesia ","code_information":[{"code":"27095","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0291U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1755.000,"maximum":2527.200,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1772.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1772.550,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1772.550,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":2018.250,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1755.000,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2527.200,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1807.650,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; 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venovenous collaterals originating at or above the heart (eg, from innominate ","code_information":[{"code":"367","type":"RC"},{"code":"93587","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"59200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; 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by lateral rhinotomy ","code_information":[{"code":"30320","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"114","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1033.840,"maximum":1054.320,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1033.840,"methodology":"fee schedule","additional_payer_notes":"Days 6. 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"}]}]},{"description":"RED BLOOD CELL DISORDERS WITHOUT MCC ","code_information":[{"code":"203","type":"RC"},{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7830.690,"maximum":9384.390,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":7830.690,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":9384.390,"methodology":"fee schedule"}]}]},{"description":"Excision of neuroma; sciatic nerve ","code_information":[{"code":"362","type":"RC"},{"code":"64786","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor; tarsal (except talus or calcaneus) ","code_information":[{"code":"28171","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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at trunk ","code_information":[{"code":"15600","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS ","code_information":[{"code":"143","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32441.660,"maximum":38878.500,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":32441.660,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":38878.500,"methodology":"fee schedule"}]}]},{"description":"Removal of lens material; intracapsular ","code_information":[{"code":"361","type":"RC"},{"code":"66920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7887.200,"maximum":9452.120,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":7887.200,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":9452.120,"methodology":"fee schedule"}]}]},{"description":"Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves ","code_information":[{"code":"27035","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Preparation of fecal microbiota for instillation, including assessment of donor specimen ","code_information":[{"code":"44705","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"ANOSCOPY WITH DIRECTED SUBMUCOSAL INJECTION OF BULKING AGENT FOR FECAL INCONTINENCE ","code_information":[{"code":"0377T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of acromioclavicular dislocation; 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1 or 2 views ","code_information":[{"code":"72170","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":37.160,"maximum":37.160,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":37.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":37.160,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; 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with biopsy, single or multiple ","code_information":[{"code":"361","type":"RC"},{"code":"44386","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Biopsy of intestine by capsule, tube, peroral (1 or more specimens) ","code_information":[{"code":"44100","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of mandibular fracture; without manipulation ","code_information":[{"code":"21450","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision of lingual frenum (frenectomy) ","code_information":[{"code":"41115","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision or fulguration; urethral polyp(s), distal urethra ","code_information":[{"code":"490","type":"RC"},{"code":"53260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Hyperbaric Oxygen ","code_information":[{"code":"5061","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":132.020,"maximum":190.110,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":133.340,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":133.340,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":133.340,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":151.820,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":132.020,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":190.110,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":135.980,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1854.720,"maximum":40533.410,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":40533.410,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":32662.160,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12180.870,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14597.190,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":28196.730,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1854.720,"methodology":"fee schedule"}]}]},{"description":"Ciliary body destruction; cyclodialysis ","code_information":[{"code":"361","type":"RC"},{"code":"66740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Application of 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 sq cm; 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intranasal, anterior ","code_information":[{"code":"31200","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Tendon sheath incision (eg, for trigger finger) ","code_information":[{"code":"26055","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"TESTES PROCEDURES WITH CC/MCC ","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":51732.420,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":51732.420,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":41686.420,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":17840.850,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":21381.850,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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with conjunctival graft or extensive rearrangement ","code_information":[{"code":"362","type":"RC"},{"code":"68326","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"REPOSITIONING OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD ONLY ","code_information":[{"code":"0433T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Epikeratoplasty ","code_information":[{"code":"369","type":"RC"},{"code":"65767","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"RED BLOOD CELL DISORDERS WITH MCC ","code_information":[{"code":"174","type":"RC"},{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12202.900,"maximum":14624.110,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12202.900,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14624.110,"methodology":"fee schedule"}]}]},{"description":"Laparoscopic treatment of ectopic pregnancy; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":22699.690,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1854.720,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with biopsy, single or multiple ","code_information":[{"code":"43202","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Removal foreign body from deep penile tissue (eg, plastic implant) ","code_information":[{"code":"367","type":"RC"},{"code":"54115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE ","code_information":[{"code":"32405","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, flexor, finger, open, each tendon ","code_information":[{"code":"26455","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous ","code_information":[{"code":"369","type":"RC"},{"code":"67027","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"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":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (eg, Stener lesion) ","code_information":[{"code":"29902","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7182.000,"maximum":7566.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7182.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":7566.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"204","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":985.530,"maximum":1005.050,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":985.530,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":985.530,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":985.530,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1005.050,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC ","code_information":[{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":74895.080,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":74895.080,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":60351.080,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":21942.840,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":26297.990,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":52100.140,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, i ","code_information":[{"code":"19086","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 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more than 4 cm length ","code_information":[{"code":"481","type":"RC"},{"code":"64893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC ","code_information":[{"code":"179","type":"RC"},{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9403.430,"maximum":11269.190,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":9403.430,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":11269.190,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"172","type":"RC"},{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5507.650,"maximum":6600.440,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":5507.650,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":6600.440,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of fracture great toe, phalanx or phalanges; with manipulation ","code_information":[{"code":"28495","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"203","type":"RC"},{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11157.880,"maximum":13371.740,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11157.880,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13371.740,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, abdomen, peritoneum and omentum ","code_information":[{"code":"360","type":"RC"},{"code":"49329","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":827.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC ","code_information":[{"code":"179","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14883.260,"maximum":17836.290,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":14883.260,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":17836.290,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"172","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10881.410,"maximum":13040.420,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":10881.410,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13040.420,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"843","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":28424.060,"maximum":40930.650,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":28708.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":28708.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":28708.300,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":28424.060,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":32687.670,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":28424.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":28424.060,"methodology":"fee 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","code_information":[{"code":"361","type":"RC"},{"code":"S2095","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"VIRAL ILLNESS WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14257.290,"maximum":17086.120,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":14257.290,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":17086.120,"methodology":"fee schedule"}]}]},{"description":"Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair) ","code_information":[{"code":"362","type":"RC"},{"code":"54318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"58540","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Removal of fecal impaction or foreign body (separate procedure) under anesthesia ","code_information":[{"code":"45915","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1854.720,"maximum":38795.590,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":38795.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":31261.810,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13109.780,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":15710.360,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":26987.830,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1854.720,"methodology":"fee schedule"}]}]},{"description":"Excision of single external papilla or tag, anus ","code_information":[{"code":"362","type":"RC"},{"code":"46220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Drug metabolism, psychiatry (eg major depressive disorder, general anxiety disorder, ADHD, schizophrenia), whole blood, buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number v ","code_information":[{"code":"0476U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":600.160,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":420.950,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":479.300,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":600.160,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":429.280,"methodology":"fee schedule"}]}]},{"description":"Claviculectomy; 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humerus, minimum of 2 views ","code_information":[{"code":"73060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.990,"maximum":42.990,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":42.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":42.990,"methodology":"fee schedule"}]}]},{"description":"Closure of vesicovaginal fistula; vaginal approach ","code_information":[{"code":"481","type":"RC"},{"code":"57320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g ","code_information":[{"code":"481","type":"RC"},{"code":"58546","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Correction of lid retraction ","code_information":[{"code":"481","type":"RC"},{"code":"67911","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips ","code_information":[{"code":"15630","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, i ","code_information":[{"code":"360","type":"RC"},{"code":"62323","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Ligation arteries; ethmoidal ","code_information":[{"code":"30915","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps ","code_information":[{"code":"361","type":"RC"},{"code":"61001","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method ","code_information":[{"code":"28298","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or ","code_information":[{"code":"369","type":"RC"},{"code":"50553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"152","type":"MS-DRG"},{"code":"174","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":10330.210,"maximum":12379.860,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":10330.210,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":12379.860,"methodology":"fee schedule"}]}]},{"description":"SKIN ULCERS WITH MCC ","code_information":[{"code":"174","type":"RC"},{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18171.330,"maximum":21776.750,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":18171.330,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":21776.750,"methodology":"fee schedule"}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC ","code_information":[{"code":"231","type":"RC"},{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15170.160,"maximum":18180.110,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":15170.160,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":18180.110,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement ","code_information":[{"code":"369","type":"RC"},{"code":"50947","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":2963.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"Open treatment of coccygeal fracture ","code_information":[{"code":"27202","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair, laceration of palate; up to 2 cm ","code_information":[{"code":"362","type":"RC"},{"code":"42180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) ","code_information":[{"code":"24341","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Revision of total hip arthroplasty; both components, with or without autograft or allograft ","code_information":[{"code":"27134","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"44300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy, indirect; with vocal cord injection ","code_information":[{"code":"31513","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19») vaccine, mRNA-LNP, 25 mcg/0.25 mL dosage, for intramuscular use ","code_information":[{"code":"91321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Aetna","plan_name":"MGMCRPPO","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Aetna","plan_name":"MGMCRSNP","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Amerigroup","plan_name":"MGMCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_percentage":11.50,"standard_charge_algorithm":"Reimbursement will be 11.5% 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":"Devoted Health Plan","plan_name":"MCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"DualEligible","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPOS","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPPO","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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 BH","plan_name":"MCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_percentage":14.40,"standard_charge_algorithm":"Reimbursement will be 14.4% 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":"Zing","plan_name":"MGMCR","standard_charge_percentage":10.30,"standard_charge_algorithm":"Reimbursement will be 10.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Excision aural glomus tumor; transcanal ","code_information":[{"code":"360","type":"RC"},{"code":"69550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of nasal septal fracture, with or without stabilization ","code_information":[{"code":"21337","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/ ","code_information":[{"code":"022","type":"MS-DRG"},{"code":"171","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":34103.950,"maximum":40870.610,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":34103.950,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":40870.610,"methodology":"fee schedule"}]}]},{"description":"Ciliary body destruction; cryotherapy ","code_information":[{"code":"499","type":"RC"},{"code":"66720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Tracheal puncture, percutaneous with transtracheal aspiration and/or injection ","code_information":[{"code":"31612","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple ","code_information":[{"code":"38572","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3068.000,"maximum":4183.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3068.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":4183.000,"methodology":"case rate"}]}]},{"description":"Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) ","code_information":[{"code":"21029","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress ","code_information":[{"code":"E0265","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":202.450,"maximum":291.530,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":204.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":204.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":204.470,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":232.820,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":202.450,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":291.530,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":208.520,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH MCC ","code_information":[{"code":"037","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":81729.670,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":81729.670,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":65858.460,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":28368.540,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":33999.040,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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without contrast material ","code_information":[{"code":"72128","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":459.250,"maximum":459.250,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":459.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":459.250,"methodology":"fee schedule"}]}]},{"description":"Reconstruction midface, LeFort I; 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excised diameter 0.6 to 1.0 cm ","code_information":[{"code":"11601","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Sesamoidectomy, thumb or finger (separate procedure) ","code_information":[{"code":"26185","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"172","type":"RC"},{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13886.930,"maximum":16642.270,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13886.930,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16642.270,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC ","code_information":[{"code":"173","type":"RC"},{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17160.220,"maximum":20565.020,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":17160.220,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":20565.020,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of other cranial nerve, extradural ","code_information":[{"code":"481","type":"RC"},{"code":"64771","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":940.690,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":940.690,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":959.310,"methodology":"fee schedule","additional_payer_notes":"Days 2. 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single tendon ","code_information":[{"code":"27390","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"171","type":"RC"},{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6157.960,"maximum":7379.780,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6157.960,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7379.780,"methodology":"fee schedule"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, inguinal; 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defect 10.1 sq cm to 30.0 sq cm ","code_information":[{"code":"14061","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; 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cornea and/or sclera, perforating, not involving uveal tissue ","code_information":[{"code":"490","type":"RC"},{"code":"65280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Inj. riabni, 10 mg ","code_information":[{"code":"9411","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":20.900,"maximum":30.090,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":21.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":21.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":21.100,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":20.900,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":30.090,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":21.520,"methodology":"fee schedule"}]}]},{"description":"CORRECTION OF BUNION ","code_information":[{"code":"28290","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Formation of direct or tubed pedicle, with or without transfer; trunk ","code_information":[{"code":"15570","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only ","code_information":[{"code":"42205","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); 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diagnostic, with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when p ","code_information":[{"code":"369","type":"RC"},{"code":"46601","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) ","code_information":[{"code":"15151","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_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":"203","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21884.540,"maximum":26226.710,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":21884.540,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":26226.710,"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":"361","type":"RC"},{"code":"49185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perfo ","code_information":[{"code":"36908","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC ","code_information":[{"code":"231","type":"RC"},{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29610.030,"maximum":35485.030,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":29610.030,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":35485.030,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, arthroscopy ","code_information":[{"code":"29999","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":827.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, symphysis pubis (including obtaining graft) ","code_information":[{"code":"27282","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children ","code_information":[{"code":"15135","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection ","code_information":[{"code":"38550","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"156","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1092.360,"maximum":1114.000,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1092.360,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":940.690,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":940.690,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":959.310,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Salpingostomy (salpingoneostomy) ","code_information":[{"code":"361","type":"RC"},{"code":"58770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed ","code_information":[{"code":"45337","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Esophageal mucosal integrity testing by electrical impedance, transoral, includes esophagoscopy or esophagogastroduodenoscopy ","code_information":[{"code":"750","type":"RC"},{"code":"C9777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ethmoidectomy; intranasal, anterior ","code_information":[{"code":"31200","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Iridoplasty by photocoagulation (1 or more sessions) (eg, for improvement of vision, for widening of anterior chamber angle) ","code_information":[{"code":"481","type":"RC"},{"code":"66762","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible ","code_information":[{"code":"481","type":"RC"},{"code":"49500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"25085","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Anterior tibial tubercleplasty (eg, Maquet type procedure) ","code_information":[{"code":"27418","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Intra-atrial pacing ","code_information":[{"code":"93610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5094.000,"maximum":30393.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":30393.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":25919.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":5094.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":6946.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation ","code_information":[{"code":"25660","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) ","code_information":[{"code":"369","type":"RC"},{"code":"65782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; 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without manipulation ","code_information":[{"code":"23500","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Capsulotomy, posterior capsular release, knee ","code_information":[{"code":"27435","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"URINARY STONES WITH MCC ","code_information":[{"code":"231","type":"RC"},{"code":"693","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12313.310,"maximum":14756.430,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12313.310,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14756.430,"methodology":"fee schedule"}]}]},{"description":"REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE; 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","code_information":[{"code":"23530","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"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":"17311","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC ","code_information":[{"code":"172","type":"RC"},{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12654.990,"maximum":15165.900,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12654.990,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":15165.900,"methodology":"fee schedule"}]}]},{"description":"Immunohistochemistry or immunocytochemistry, per specimen; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":82219.020,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Repair lateral collateral ligament, elbow, with local tissue ","code_information":[{"code":"24343","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent ","code_information":[{"code":"66174","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright 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customary and prevailing profiles","setting":"outpatient","minimum":123.210,"maximum":123.210,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":123.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":123.210,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) ","code_information":[{"code":"72159","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":964.860,"maximum":964.860,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":964.860,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":964.860,"methodology":"fee schedule"}]}]},{"description":"Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls ","code_information":[{"code":"362","type":"RC"},{"code":"42892","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); LAPAROSCOPIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, ANTERIOR AND POSTERIOR VAGAL TRUNKS 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","code_information":[{"code":"481","type":"RC"},{"code":"63076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5310.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus ","code_information":[{"code":"23184","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Removal of epicranial neurostimulator system ","code_information":[{"code":"0969T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SEPTIC ARTHRITIS WITHOUT CC/MCC ","code_information":[{"code":"170","type":"RC"},{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8202.790,"maximum":9830.330,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":8202.790,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":9830.330,"methodology":"fee schedule"}]}]},{"description":"Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) ","code_information":[{"code":"362","type":"RC"},{"code":"64616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon ","code_information":[{"code":"367","type":"RC"},{"code":"61623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated ","code_information":[{"code":"36478","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"173","type":"RC"},{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12275.060,"maximum":14710.590,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12275.060,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14710.590,"methodology":"fee schedule"}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":31433.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":31433.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":26806.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12257.230,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14690.010,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":26495.630,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) ","code_information":[{"code":"87181","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.770,"maximum":6.840,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":3.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":4.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":4.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":4.800,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3.770,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":5.460,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":6.840,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":4.890,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29827.380,"maximum":35745.510,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":29827.380,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":35745.510,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, radial head; with implant ","code_information":[{"code":"24366","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, ","code_information":[{"code":"360","type":"RC"},{"code":"36224","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC  IPF","code_information":[{"code":"056","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1020.900,"maximum":1041.120,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1020.900,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1020.900,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1020.900,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1041.120,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITH CC/MCC ","code_information":[{"code":"121","type":"MS-DRG"},{"code":"179","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11138.750,"maximum":13348.820,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11138.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13348.820,"methodology":"fee schedule"}]}]},{"description":"Capsulotomy, midfoot; medial release only (separate procedure) ","code_information":[{"code":"28260","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC ","code_information":[{"code":"113","type":"RC"},{"code":"277","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":41578.190,"maximum":49827.830,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":41578.190,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":49827.830,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"23030","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Repair, extensor tendon, leg; primary, without graft, each tendon 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with manipulation ","code_information":[{"code":"27268","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"INSERT BILE DUCT DRAIN ","code_information":[{"code":"47511","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages) ","code_information":[{"code":"499","type":"RC"},{"code":"66821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Donor hysterectomy (including cold preservation); open, from cadaver donor ","code_information":[{"code":"0664T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ostectomy, complete excision; other metatarsal head (second, third or fourth) ","code_information":[{"code":"28112","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1023.610,"maximum":1177.150,"payers_information":[{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":1177.150,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1023.610,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1023.610,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"1000","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1460.170,"maximum":1460.170,"payers_information":[{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1460.170,"methodology":"fee schedule","additional_payer_notes":"Days 1. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":26507.720,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"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":"367","type":"RC"},{"code":"43284","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Repair of enterocele, vaginal approach (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"57268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"28555","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection ","code_information":[{"code":"38550","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"New Technology - Level 19 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further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal joint ","code_information":[{"code":"28020","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated ","code_information":[{"code":"480","type":"RC"},{"code":"49507","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":984.440,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":984.440,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1003.930,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Fern test ","code_information":[{"code":"Q0114","type":"HCPCS"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":7.750,"maximum":7.750,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":7.750,"methodology":"fee schedule"}]}]},{"description":"Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure ","code_information":[{"code":"22844","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngeal reinnervation by neuromuscular pedicle ","code_information":[{"code":"31590","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm ","code_information":[{"code":"28043","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC ","code_information":[{"code":"171","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13874.750,"maximum":16627.680,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13874.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16627.680,"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":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14640.700,"maximum":17545.600,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":14640.700,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":17545.600,"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"172","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":99641.060,"maximum":119411.120,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":99641.060,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":119411.120,"methodology":"fee schedule"}]}]},{"description":"Varicella-zoster ig, im ","code_information":[{"code":"9135","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2363.390,"maximum":3403.280,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":2387.020,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":2387.020,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":2387.020,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":2717.900,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":2363.390,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":3403.280,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":2434.290,"methodology":"fee schedule"}]}]},{"description":"TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) ","code_information":[{"code":"20926","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Closure of urethrovaginal fistula; ","code_information":[{"code":"361","type":"RC"},{"code":"57310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Perineoplasty, repair of perineum, nonobstetrical (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"56810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Sympathectomy; radial artery ","code_information":[{"code":"480","type":"RC"},{"code":"64821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use ","code_information":[{"code":"90684","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Aetna","plan_name":"MGMCRPPO","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Aetna","plan_name":"MGMCRSNP","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Amerigroup","plan_name":"MGMCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_percentage":11.50,"standard_charge_algorithm":"Reimbursement will be 11.5% 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":"Devoted Health Plan","plan_name":"MCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"DualEligible","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPOS","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPPO","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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 BH","plan_name":"MCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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with implant (total ankle) ","code_information":[{"code":"27702","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent ","code_information":[{"code":"369","type":"RC"},{"code":"66174","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"PLACEMENT OF INTRAOCULAR RADIATION SOURCE APPLICATOR (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) ","code_information":[{"code":"0190T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance ","code_information":[{"code":"490","type":"RC"},{"code":"59074","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL ","code_information":[{"code":"0228T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16313.420,"maximum":19550.210,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":16313.420,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":19550.210,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve ","code_information":[{"code":"362","type":"RC"},{"code":"93591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3114.000,"maximum":4247.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3114.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":4247.000,"methodology":"case rate"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13393.980,"maximum":16051.510,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13393.980,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16051.510,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; 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multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Release, tarsal tunnel (posterior tibial nerve decompression) ","code_information":[{"code":"28035","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright 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","code_information":[{"code":"26765","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Transfer iliopsoas; to femoral neck 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":18900.290,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1854.720,"methodology":"fee schedule"}]}]},{"description":"Proctopexy (eg, for prolapse); perineal approach ","code_information":[{"code":"45541","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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may be further adjusted for multiple procedure logic."}]}]},{"description":"Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) ","code_information":[{"code":"36821","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of extraparenchymal lesion of testis ","code_information":[{"code":"490","type":"RC"},{"code":"54512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 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multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological superv ","code_information":[{"code":"36222","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"CORNEAL INCISIONS IN THE RECIPIENT CORNEA CREATED USING A LASER, IN PREPARATION FOR PENETRATING OR LAMELLAR KERATOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ","code_information":[{"code":"0290T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case 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be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral ","code_information":[{"code":"27392","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":2672.000,"maximum":2672.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2672.000,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2672.000,"methodology":"fee schedule"}]}]},{"description":"Destruction of lesion (except excision), dentoalveolar structures ","code_information":[{"code":"360","type":"RC"},{"code":"41850","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of clavicle or scapula; 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","code_information":[{"code":"28415","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"134","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1149.790,"maximum":1172.560,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1149.790,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1149.790,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1149.790,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1172.560,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"HTransperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance ","code_information":[{"code":"0438T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC ","code_information":[{"code":"179","type":"RC"},{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18897.280,"maximum":22646.740,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":18897.280,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":22646.740,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; less than 3 cm ","code_information":[{"code":"25077","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"1001","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1603.320,"maximum":1603.320,"payers_information":[{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1603.320,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Venography for congenital heart defect(s), including catheter placement, and radiological supervision and interpretation; venovenous collaterals originating below the heart (eg, from the inferior vena ","code_information":[{"code":"750","type":"RC"},{"code":"93588","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CORONARY BYPASS WITH PTCA WITH MCC ","code_information":[{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":209280.700,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":209280.700,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":168640.150,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":68200.140,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":81736.290,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Multiplan","plan_name":"COMM","standard_charge_dollar":35691.910,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess ","code_information":[{"code":"369","type":"RC"},{"code":"45020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH MCC ","code_information":[{"code":"171","type":"RC"},{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":24499.690,"maximum":29360.740,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":24499.690,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":29360.740,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT ","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":530047.510,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":530047.510,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":427116.750,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1556.620,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1556.620,"methodology":"fee schedule","additional_payer_notes":"Days 1. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Multiplan","plan_name":"COMM","standard_charge_dollar":26421.370,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1854.720,"methodology":"fee schedule"}]}]},{"description":"Dilation of anal sphincter (separate procedure) under anesthesia other than local ","code_information":[{"code":"45905","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision first and/or cervical rib; 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each additional lesion, i ","code_information":[{"code":"19082","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Relocation of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing dual leads ","code_information":[{"code":"0681T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_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 over 4.0 cm ","code_information":[{"code":"11626","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length ","code_information":[{"code":"499","type":"RC"},{"code":"64891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, knee; 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3 cm or greater ","code_information":[{"code":"21552","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"072","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":6807.400,"maximum":8158.080,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6807.400,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":8158.080,"methodology":"fee schedule"}]}]},{"description":"Paravaginal defect repair (including repair of cystocele, if performed); 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"}]}]},{"description":"Biopsy of penis; (separate procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"54100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) ","code_information":[{"code":"490","type":"RC"},{"code":"52345","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Tonsillectomy and adenoidectomy; 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","code_information":[{"code":"30801","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  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"}]}]},{"description":"Radiologic examination, ribs, bilateral; 3 views ","code_information":[{"code":"71110","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":59.070,"maximum":59.070,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":59.070,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":59.070,"methodology":"fee schedule"}]}]},{"description":"Removal foreign body from deep penile tissue (eg, plastic implant) ","code_information":[{"code":"361","type":"RC"},{"code":"54115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Adenoidectomy, primary; 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partial, simple repair ","code_information":[{"code":"499","type":"RC"},{"code":"69110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) ","code_information":[{"code":"499","type":"RC"},{"code":"65730","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1530.080,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1530.080,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1560.370,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral ","code_information":[{"code":"31573","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (1 or more stages) ","code_information":[{"code":"67031","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space ","code_information":[{"code":"0474T","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) ","code_information":[{"code":"0095T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 cm or greater ","code_information":[{"code":"28047","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; both components of pul ","code_information":[{"code":"0517T","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"231","type":"RC"},{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10398.020,"maximum":12461.120,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":10398.020,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":12461.120,"methodology":"fee schedule"}]}]},{"description":"Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter ","code_information":[{"code":"369","type":"RC"},{"code":"50396","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including s ","code_information":[{"code":"19081","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITH CC/MCC ","code_information":[{"code":"121","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11138.750,"maximum":13348.820,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11138.750,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13348.820,"methodology":"fee schedule"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"154","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1214.870,"maximum":1238.930,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1214.870,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Open treatment of talotarsal joint dislocation, includes internal fixation, when performed ","code_information":[{"code":"28585","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required ","code_information":[{"code":"86153","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 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donor nephrectomy (including cold preservation), from living donor ","code_information":[{"code":"50547","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5310.000,"maximum":6227.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6227.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5310.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision (eg, osteomyelitis or bone abscess), leg or ankle ","code_information":[{"code":"27607","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC ","code_information":[{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":79264.450,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":79264.450,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":63871.960,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":29036.660,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":34799.770,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":55139.660,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIVATED CARDIAC EVENT RECORDER ","code_information":[{"code":"33284","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Blood bank physician services; 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"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1041.120,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1041.120,"methodology":"fee schedule","additional_payer_notes":"Days 7. 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with allograft ","code_information":[{"code":"23146","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination; scapula, complete ","code_information":[{"code":"73010","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":31.730,"maximum":31.730,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":31.730,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":31.730,"methodology":"fee schedule"}]}]},{"description":"KIDNEY TRANSPLANT ","code_information":[{"code":"171","type":"RC"},{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26120.250,"maximum":31302.840,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":26120.250,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":31302.840,"methodology":"fee schedule"}]}]},{"description":"Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"43752","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Nfct Agent HIV Trgt Viral Next-Gnrj Seq Alys Alg 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"}]}]},{"description":"Open treatment of greater trochanteric fracture, includes internal fixation, when performed ","code_information":[{"code":"27248","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region ","code_information":[{"code":"27301","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"174","type":"RC"},{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9677.290,"maximum":11597.390,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":9677.290,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":11597.390,"methodology":"fee schedule"}]}]},{"description":"Exchange transfusion, blood; newborn ","code_information":[{"code":"36450","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Lt vent pacing syst, sequ ","code_information":[{"code":"2074","type":"APC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_percentage":19.09,"standard_charge_algorithm":"Reimbursement will be 19.09% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCRPPO","standard_charge_percentage":19.09,"standard_charge_algorithm":"Reimbursement will be 19.09% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MGMCRSNP","standard_charge_percentage":19.09,"standard_charge_algorithm":"Reimbursement will be 19.09% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_percentage":21.73,"standard_charge_algorithm":"Reimbursement will be 21.73% 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."},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"DualEligible","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPOS","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPPO","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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 BH","plan_name":"MCR","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_percentage":27.22,"standard_charge_algorithm":"Reimbursement will be 27.22% 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":"Zing","plan_name":"MGMCR","standard_charge_percentage":19.47,"standard_charge_algorithm":"Reimbursement will be 19.47% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic ","code_information":[{"code":"45990","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":" Trauma Response - Level IV Trauma  ","code_information":[{"code":"684","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7500.000,"maximum":7500.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_percentage":37.00,"standard_charge_algorithm":"Reimbursement will be 37% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Bright Health","plan_name":"MCRNarrow","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":"Bright Health","plan_name":"SmallGroup","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":"Zing","plan_name":"MGMCR","standard_charge_dollar":7500.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29870","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":1714.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Percutaneous treatment of mandibular fracture, with external fixation ","code_information":[{"code":"21452","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, femur or knee ","code_information":[{"code":"27365","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":2007.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral ","code_information":[{"code":"490","type":"RC"},{"code":"69706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheteriz ","code_information":[{"code":"367","type":"RC"},{"code":"C7523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Es sph augmnt device removal ","code_information":[{"code":"0393T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":" Room & Board - Semi-private (Two Beds) Psychiatric  ","code_information":[{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":675.000,"maximum":2500.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2500.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NAP","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":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1895.000,"methodology":"per diem"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":764.000,"methodology":"per diem"},{"payer_name":"BCBS","plan_name":"BLUECAREBH","standard_charge_dollar":675.000,"methodology":"per diem"},{"payer_name":"BCBS","plan_name":"BLUECAREPLUS","standard_charge_dollar":675.000,"methodology":"per diem"},{"payer_name":"BCBS","plan_name":"MABehavioralHealth","standard_charge_dollar":1200.000,"methodology":"per diem"},{"payer_name":"BCBS","plan_name":"StandardBH","standard_charge_dollar":1473.000,"methodology":"per diem"},{"payer_name":"BCBS","plan_name":"TENNCARESELECTBH","standard_charge_dollar":675.000,"methodology":"per diem"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_dollar":1655.000,"methodology":"per diem"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":915.000,"methodology":"per diem"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":915.000,"methodology":"per diem"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":915.000,"methodology":"per diem"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":915.000,"methodology":"per diem"},{"payer_name":"Humana BH","plan_name":"COMM","standard_charge_dollar":1468.000,"methodology":"per diem"},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Multiplan","plan_name":"COMM","standard_charge_dollar":1802.000,"methodology":"per diem"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":796.800,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"MCD","standard_charge_dollar":680.000,"methodology":"per diem"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC ","code_information":[{"code":"143","type":"RC"},{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9403.430,"maximum":11269.190,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":9403.430,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":11269.190,"methodology":"fee schedule"}]}]},{"description":"Therapeutic procedure, 1 or more areas, each 15 minutes; 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","code_information":[{"code":"78230","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":234.130,"maximum":234.130,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":234.130,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":234.130,"methodology":"fee schedule"}]}]},{"description":"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC ","code_information":[{"code":"170","type":"RC"},{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16365.590,"maximum":19612.730,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":16365.590,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":19612.730,"methodology":"fee schedule"}]}]},{"description":"Open treatment of hip dislocation, traumatic, without internal fixation ","code_information":[{"code":"27253","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"179","type":"RC"},{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6171.000,"maximum":7395.410,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6171.000,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7395.410,"methodology":"fee schedule"}]}]},{"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":"480","type":"RC"},{"code":"50430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL ","code_information":[{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":69434.040,"maximum":87699.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":87699.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":74435.000,"methodology":"case rate"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":939.050,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":957.640,"methodology":"fee schedule","additional_payer_notes":"Days 9. 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urethral polyp(s), distal urethra ","code_information":[{"code":"361","type":"RC"},{"code":"53260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":80785.610,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"174","type":"RC"},{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11863.830,"maximum":14217.770,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11863.830,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14217.770,"methodology":"fee schedule"}]}]},{"description":"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16365.590,"maximum":19612.730,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":16365.590,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":19612.730,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy with synovectomy, hip joint ","code_information":[{"code":"27054","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve rootºs» ºeg, spinal or lateral recess stenosis»), during posterior inter ","code_information":[{"code":"480","type":"RC"},{"code":"63052","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or destruction lingual tonsil, any method (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"42870","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision or destruction (eg, laser), intranasal lesion; internal approach ","code_information":[{"code":"30117","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"1001","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1603.320,"maximum":1603.320,"payers_information":[{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1603.320,"methodology":"fee schedule","additional_payer_notes":"Days 1. 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collateral ","code_information":[{"code":"27695","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C ","code_information":[{"code":"481","type":"RC"},{"code":"58558","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, elbow, surgical; 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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":295.390,"maximum":295.390,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":295.390,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":295.390,"methodology":"fee schedule"}]}]},{"description":"Insertion of ocular implant secondary; after enucleation, muscles attached to implant ","code_information":[{"code":"481","type":"RC"},{"code":"65140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"EPISTAXIS WITHOUT MCC ","code_information":[{"code":"151","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":6700.470,"maximum":8029.920,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6700.470,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":8029.920,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) ","code_information":[{"code":"23420","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft ","code_information":[{"code":"66185","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"43270","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning ","code_information":[{"code":"27178","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Labyrinthectomy; transcanal ","code_information":[{"code":"69905","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Cochlear device implantation, with or without mastoidectomy ","code_information":[{"code":"490","type":"RC"},{"code":"69930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm ","code_information":[{"code":"13121","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Chemodenervation of trunk muscle(s); 1-5 muscle(s) ","code_information":[{"code":"481","type":"RC"},{"code":"64646","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed ","code_information":[{"code":"27280","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Strabismus surgery, any procedure, superior oblique muscle ","code_information":[{"code":"361","type":"RC"},{"code":"67318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITH MCC ","code_information":[{"code":"174","type":"RC"},{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13493.960,"maximum":16171.330,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13493.960,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16171.330,"methodology":"fee schedule"}]}]},{"description":"Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm ","code_information":[{"code":"14021","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITH CC ","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":52350.590,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":52350.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":42184.540,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":17692.940,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":21204.580,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":36417.250,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor ","code_information":[{"code":"52355","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"36903","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, lengthening, or release, abductor hallucis muscle ","code_information":[{"code":"28240","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) ","code_information":[{"code":"11980","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; 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cryotherapy, diathermy ","code_information":[{"code":"369","type":"RC"},{"code":"67141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22845","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; ","code_information":[{"code":"369","type":"RC"},{"code":"67036","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Open treatment of sternoclavicular dislocation, acute or chronic; ","code_information":[{"code":"23530","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M ","code_information":[{"code":"203","type":"RC"},{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11434.350,"maximum":13703.070,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11434.350,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13703.070,"methodology":"fee schedule"}]}]},{"description":"Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head ","code_information":[{"code":"28288","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; 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","code_information":[{"code":"23480","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Construction of artificial vagina; with graft ","code_information":[{"code":"369","type":"RC"},{"code":"57292","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Excision of fibrous tuberosities, dentoalveolar structures ","code_information":[{"code":"41822","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC ","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":96071.750,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":45431.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":36609.150,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":80167.370,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":96071.750,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":31604.100,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local) ","code_information":[{"code":"360","type":"RC"},{"code":"57415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"OSTEOMYELITIS WITH MCC ","code_information":[{"code":"172","type":"RC"},{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17252.370,"maximum":20675.460,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":17252.370,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":20675.460,"methodology":"fee schedule"}]}]},{"description":"Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction ","code_information":[{"code":"481","type":"RC"},{"code":"69645","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":5078.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy ","code_information":[{"code":"15953","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION  IPF","code_information":[{"code":"134","type":"RC"},{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1102.570,"maximum":1124.410,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1102.570,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor; clavicle ","code_information":[{"code":"23200","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Probing of lacrimal canaliculi, with or without irrigation ","code_information":[{"code":"499","type":"RC"},{"code":"68840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Ostectomy, calcaneus; ","code_information":[{"code":"28118","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case 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procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary neurorrhaphy) ","code_information":[{"code":"480","type":"RC"},{"code":"64872","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"174","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6524.850,"maximum":7819.460,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6524.850,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7819.460,"methodology":"fee schedule"}]}]},{"description":"Transcatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography ","code_information":[{"code":"0800T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for 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","code_information":[{"code":"26850","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"PSYCHOSES  IPF","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":929.570,"maximum":1069.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":1069.000,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":929.570,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":929.570,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC ","code_information":[{"code":"083","type":"MS-DRG"},{"code":"174","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11792.540,"maximum":14132.330,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11792.540,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14132.330,"methodology":"fee schedule"}]}]},{"description":"Lengthening of hamstring tendon; multiple tendons, 1 leg ","code_information":[{"code":"27394","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC ","code_information":[{"code":"193","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11533.460,"maximum":13821.850,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11533.460,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":13821.850,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) ","code_information":[{"code":"367","type":"RC"},{"code":"52332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":1187.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"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":"480","type":"RC"},{"code":"C7513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endomyocardial biopsy ","code_information":[{"code":"750","type":"RC"},{"code":"93505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":827.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"57267","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal 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TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":90.130,"maximum":90.130,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":90.130,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":90.130,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC  IPF","code_information":[{"code":"056","type":"MS-DRG"},{"code":"146","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1041.320,"maximum":1061.940,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1041.320,"methodology":"fee schedule","additional_payer_notes":"Days 8. 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","code_information":[{"code":"490","type":"RC"},{"code":"67041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":994.280,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":994.280,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1013.970,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Removal of implanted intra-arterial infusion pump ","code_information":[{"code":"36262","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee 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","code_information":[{"code":"31276","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of talus fracture; with manipulation 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","code_information":[{"code":"499","type":"RC"},{"code":"60240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) ","code_information":[{"code":"67015","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body 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","code_information":[{"code":"41512","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Capsulotomy, midtarsal (eg, Heyman type procedure) ","code_information":[{"code":"28264","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC INJURY WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12993.180,"maximum":15571.200,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12993.180,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":15571.200,"methodology":"fee schedule"}]}]},{"description":"Anoscopy, high resolution (hra) (with magnification and chemical agent enhancement); with biopsy(ies) ","code_information":[{"code":"490","type":"RC"},{"code":"G6028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when performed ","code_information":[{"code":"27513","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Open treatment of 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","code_information":[{"code":"17250","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"TREAT HYOID BONE FRACTURE ","code_information":[{"code":"21495","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance (eg, fibrin glue), if ","code_information":[{"code":"31634","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele ","code_information":[{"code":"362","type":"RC"},{"code":"58294","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Excision of chalazion; multiple, same lid ","code_information":[{"code":"367","type":"RC"},{"code":"67801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Repair and reconstruction, finger, volar plate, interphalangeal joint ","code_information":[{"code":"26548","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC ","code_information":[{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":66965.650,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":66965.650,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":53961.490,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":23089.150,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":27671.810,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":46584.100,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, hip, surgical; with removal of loose body or foreign body ","code_information":[{"code":"29861","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":2007.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies ","code_information":[{"code":"27331","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck ","code_information":[{"code":"490","type":"RC"},{"code":"51715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"1000","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1124.410,"maximum":1124.410,"payers_information":[{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1124.410,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29830","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":1714.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; cholecystectomy ","code_information":[{"code":"47562","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":2559.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system ","code_information":[{"code":"33264","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"64859","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1143.410,"maximum":1166.050,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1143.410,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1143.410,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1143.410,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1166.050,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) ","code_information":[{"code":"20702","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"203","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6550.930,"maximum":7850.720,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6550.930,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7850.720,"methodology":"fee schedule"}]}]},{"description":"Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus ","code_information":[{"code":"480","type":"RC"},{"code":"64714","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Obecabtagene autoleucel, 10 up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion ","code_information":[{"code":"636","type":"RC"},{"code":"Q2058","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $4409 reimbursement is 35% of aggregated billable gross charges. If aggregated billable gross charges are less than $4409 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $4082 reimbursement is 28% of aggregated billable gross charges. If aggregated billable gross charges are less than $4082 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Percutaneous transcatheter closure of patent ductus arteriosus ","code_information":[{"code":"367","type":"RC"},{"code":"93582","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3114.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3114.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":4247.000,"methodology":"case rate"}]}]},{"description":"Removal of indwelling tunneled pleural catheter with cuff ","code_information":[{"code":"32552","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":25694.250,"maximum":30792.310,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":25694.250,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":30792.310,"methodology":"fee schedule"}]}]},{"description":"Knee orthosis, adjustable knee joints (unicentric or polycentric), 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral 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upper extremity ","code_information":[{"code":"35206","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of amniotic membrane on the ocular surface; single layer, sutured ","code_information":[{"code":"499","type":"RC"},{"code":"65779","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Transcranial Doppler study of the intracranial arteries; 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by injections (includes imaging guidance, when performed) ","code_information":[{"code":"64488","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29157.940,"maximum":34943.240,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":29157.940,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":34943.240,"methodology":"fee schedule"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique) ","code_information":[{"code":"67316","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"174","type":"RC"},{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10711.010,"maximum":12836.210,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":10711.010,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":12836.210,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa ","code_information":[{"code":"31295","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for pri ","code_information":[{"code":"15772","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) ","code_information":[{"code":"49322","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":2007.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"},{"code":"231","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":6732.630,"maximum":8068.470,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":6732.630,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":8068.470,"methodology":"fee schedule"}]}]},{"description":"Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) ","code_information":[{"code":"21348","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cm ","code_information":[{"code":"26117","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source) ","code_information":[{"code":"67218","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"170","type":"RC"},{"code":"458","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":39392.510,"maximum":47208.490,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":39392.510,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":47208.490,"methodology":"fee schedule"}]}]},{"description":"Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff ","code_information":[{"code":"361","type":"RC"},{"code":"53445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, talus or calcaneus; 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","code_information":[{"code":"0918T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, de 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","code_information":[{"code":"361","type":"RC"},{"code":"G0308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Release, tarsal tunnel (posterior tibial nerve decompression) ","code_information":[{"code":"28035","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27827.760,"maximum":33349.140,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":27827.760,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":33349.140,"methodology":"fee 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system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) ","code_information":[{"code":"36012","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Fine needle aspiration biopsy, including CT guidance; first lesion ","code_information":[{"code":"10009","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LUNG TRANSPLANT ","code_information":[{"code":"007","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":106644.080,"maximum":127803.620,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":106644.080,"methodology":"fee schedule"},{"payer_name":"Bright 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Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, hands or fingers ","code_information":[{"code":"26989","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Dactinomycin injection ","code_information":[{"code":"752","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":307.990,"maximum":443.500,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":311.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":311.060,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":311.060,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":307.990,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":354.180,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":307.990,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":307.990,"methodology":"fee 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","code_information":[{"code":"27045","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft) ","code_information":[{"code":"25135","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Repair of syndactyly (web finger) each web space; with skin flaps ","code_information":[{"code":"26560","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each throu ","code_information":[{"code":"36476","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Amputation, toe; metatarsophalangeal joint ","code_information":[{"code":"28820","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm ","code_information":[{"code":"13152","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case 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","code_information":[{"code":"27612","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"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":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasonic guidance for interstitial radioelement application ","code_information":[{"code":"76965","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":128.420,"maximum":128.420,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":128.420,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":128.420,"methodology":"fee schedule"}]}]},{"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 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logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block ","code_information":[{"code":"23465","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection ","code_information":[{"code":"38555","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright 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multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Change of cystostomy tube; simple ","code_information":[{"code":"480","type":"RC"},{"code":"51705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11404","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of proximal tibiofibular joint dislocation; without anesthesia ","code_information":[{"code":"27830","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance ","code_information":[{"code":"32556","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case 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","code_information":[{"code":"26541","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Colpopexy, abdominal approach 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further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy with biopsy; metatarsophalangeal joint ","code_information":[{"code":"28052","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; with cyclectomy ","code_information":[{"code":"480","type":"RC"},{"code":"66605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 ","code_information":[{"code":"22551","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2174.000,"maximum":2963.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":2174.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2963.000,"methodology":"case rate"}]}]},{"description":"Repair, secondary, Achilles tendon, with or without graft ","code_information":[{"code":"27654","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case 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","code_information":[{"code":"31800","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component ","code_information":[{"code":"23334","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) ","code_information":[{"code":"67901","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"172","type":"RC"},{"code":"716","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12364.610,"maximum":14817.900,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12364.610,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14817.900,"methodology":"fee schedule"}]}]},{"description":"LIVER TRANSPLANT WITHOUT MCC ","code_information":[{"code":"006","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":115118.160,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":115118.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":92763.180,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":40649.310,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":48717.260,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":80080.990,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Eribulin mesylate injecti ","code_information":[{"code":"1426","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":72.610,"maximum":104.560,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":73.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":73.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":73.330,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":83.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":72.610,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":104.560,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":74.790,"methodology":"fee schedule"}]}]},{"description":"Excision, nasal polyp(s), extensive ","code_information":[{"code":"30115","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm ","code_information":[{"code":"13132","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":51174.000,"maximum":73238.620,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":66035.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":51174.000,"methodology":"case rate"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":96128.270,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral ","code_information":[{"code":"27332","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Amniocentesis; 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with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"25025","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH ","code_information":[{"code":"003","type":"MS-DRG"},{"code":"171","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":185358.690,"maximum":222136.210,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":185358.690,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":222136.210,"methodology":"fee schedule"}]}]},{"description":"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20723.890,"maximum":24835.770,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":20723.890,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":24835.770,"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, hip, including exploration or removal of loose or foreign body ","code_information":[{"code":"27033","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES ","code_information":[{"code":"153","type":"RC"},{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27826.020,"maximum":33347.050,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":27826.020,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":33347.050,"methodology":"fee schedule"}]}]},{"description":"Removal of implanted material, anterior segment of eye ","code_information":[{"code":"369","type":"RC"},{"code":"65920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. 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prostatomembranous ","code_information":[{"code":"362","type":"RC"},{"code":"53515","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC ","code_information":[{"code":"170","type":"RC"},{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17236.720,"maximum":20656.710,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":17236.720,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":20656.710,"methodology":"fee schedule"}]}]},{"description":"Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of maligna ","code_information":[{"code":"0245U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1266.070,"maximum":1823.140,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1278.730,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1278.730,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1278.730,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":1455.980,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1266.070,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1823.140,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1304.050,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration biopsy, without imaging guidance; 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first lesion, including ultrasound guidance ","code_information":[{"code":"19285","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, fascial defect of leg ","code_information":[{"code":"27656","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Division of sternocleidomastoid for torticollis, open operation; without cast application ","code_information":[{"code":"21720","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use ","code_information":[{"code":"90677","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Aetna","plan_name":"MGMCRPPO","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Aetna","plan_name":"MGMCRSNP","standard_charge_percentage":10.10,"standard_charge_algorithm":"Reimbursement will be 10.1% 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":"Amerigroup","plan_name":"MGMCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_percentage":11.50,"standard_charge_algorithm":"Reimbursement will be 11.5% 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":"Devoted Health Plan","plan_name":"MCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"DualEligible","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPOS","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"MCRPPO","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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 BH","plan_name":"MCR","standard_charge_percentage":10.00,"standard_charge_algorithm":"Reimbursement will be 10% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_percentage":14.40,"standard_charge_algorithm":"Reimbursement will be 14.4% 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":"Zing","plan_name":"MGMCR","standard_charge_percentage":10.30,"standard_charge_algorithm":"Reimbursement will be 10.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Hereditary prostate cancer-related disorders,genomic sequence analysis panel using next-generation sequencing (NGS),Sanger sequencing, multiplex ligation-dependent probe amplification (MLPA),and array ","code_information":[{"code":"0475U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1303.950,"maximum":1877.690,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1316.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1316.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1316.990,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":1303.950,"methodology":"fee schedule"},{"payer_name":"Bright 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"}]}]},{"description":"Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation e ","code_information":[{"code":"0489T","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"REPAIR ARTERIAL BLOCKAGE ","code_information":[{"code":"35475","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5956.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose ","code_information":[{"code":"636","type":"RC"},{"code":"Q2055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $4409 reimbursement is 35% of aggregated billable gross charges. If aggregated billable gross charges are less than $4409 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $4082 reimbursement is 28% of aggregated billable gross charges. If aggregated billable gross charges are less than $4082 then reimbursement for the specified code will be zero.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Arthroplasty, temporomandibular joint, with allograft ","code_information":[{"code":"21242","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC ","code_information":[{"code":"203","type":"RC"},{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18039.180,"maximum":21618.380,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":18039.180,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":21618.380,"methodology":"fee schedule"}]}]},{"description":"Harvest of skin for skin cell suspension autograft; 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(eg, Hauser type procedure) ","code_information":[{"code":"27420","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot ","code_information":[{"code":"28090","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Bradykinin ","code_information":[{"code":"82286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.100,"maximum":7.430,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":4.100,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":5.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":5.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":5.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4.100,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":5.930,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":5.160,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7.430,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":5.310,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging ","code_information":[{"code":"75559","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":1089.860,"maximum":1089.860,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":1089.860,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1089.860,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1142.590,"maximum":1165.210,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1142.590,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1142.590,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1142.590,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1165.210,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Exchange transfusion, blood; other than newborn ","code_information":[{"code":"362","type":"RC"},{"code":"36455","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Inj, faricimab-svoa, 0.1m ","code_information":[{"code":"9496","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":32.900,"maximum":47.370,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":33.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":33.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":33.230,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":37.830,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":47.370,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":33.880,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"170","type":"RC"},{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35165.490,"maximum":42142.770,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":35165.490,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":42142.770,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, inc ","code_information":[{"code":"36225","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair blood vessel, direct; upper extremity ","code_information":[{"code":"35206","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, pl ","code_information":[{"code":"360","type":"RC"},{"code":"44378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"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":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Carbonic anhydrase VI (CA VI),paraotid specific/secretory protein (PSP) and salivary protein (SP1 IgG,IgM,IgA antibodies, enzyme-linked immunosorbent assay (ELISA), semiqualitative,blood,reported as ","code_information":[{"code":"0472U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.900,"maximum":40.180,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":28.180,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":28.180,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":28.180,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":32.080,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":40.180,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":28.740,"methodology":"fee schedule"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm ","code_information":[{"code":"11426","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure ","code_information":[{"code":"15922","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"146","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1174.040,"maximum":1197.280,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1174.040,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1174.040,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1174.040,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1197.280,"methodology":"fee schedule","additional_payer_notes":"Days 3. 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1041.320,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1041.320,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1061.940,"methodology":"fee schedule","additional_payer_notes":"Days 8. 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with manipulation ","code_information":[{"code":"27810","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) ","code_information":[{"code":"20670","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"170","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13703.480,"maximum":16422.430,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":13703.480,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16422.430,"methodology":"fee schedule"}]}]},{"description":"REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION LEAD ONLY ","code_information":[{"code":"0430T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) ","code_information":[{"code":"28230","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"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":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1854.720,"maximum":19768.940,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":19768.940,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":15929.980,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":5984.560,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":7171.720,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":13752.100,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1854.720,"methodology":"fee schedule"}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"174","type":"RC"},{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29157.940,"maximum":34943.240,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":29157.940,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":34943.240,"methodology":"fee schedule"}]}]},{"description":"Ureterotomy for insertion of indwelling stent, all types ","code_information":[{"code":"360","type":"RC"},{"code":"50605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"1001","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":985.340,"maximum":985.340,"payers_information":[{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":985.340,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Tenodesis of biceps tendon at elbow (separate procedure) ","code_information":[{"code":"24340","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm ","code_information":[{"code":"11642","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Sympathectomy, cervical ","code_information":[{"code":"367","type":"RC"},{"code":"64802","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Excision, ischial pressure ulcer, with primary suture; 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with synovial biopsy only ","code_information":[{"code":"24100","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Unlisted hysteroscopy procedure, uterus ","code_information":[{"code":"367","type":"RC"},{"code":"58579","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Reconstruction of tendon pulley, each tendon; 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1.1 cm to 2.5 cm ","code_information":[{"code":"13120","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula ","code_information":[{"code":"23182","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; 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4 to 7 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22846","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lacrimal gland tumor; involving osteotomy ","code_information":[{"code":"481","type":"RC"},{"code":"68550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1048.250,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1048.250,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1069.000,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, ","code_information":[{"code":"750","type":"RC"},{"code":"C7540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8418.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia ","code_information":[{"code":"490","type":"RC"},{"code":"68811","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Removal of intra-aortic balloon assist device, percutaneous ","code_information":[{"code":"33968","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening ","code_information":[{"code":"27259","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motionºs» and/or ejection fractionºs», when performed); single study, at rest or stress (exercise or ","code_information":[{"code":"78491","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":2672.000,"maximum":2672.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2672.000,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2672.000,"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 up to 100 sq cm; first 25 sq ","code_information":[{"code":"499","type":"RC"},{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Thyroid imaging (including vascular flow, when performed); ","code_information":[{"code":"78013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":261.040,"maximum":261.040,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":261.040,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":261.040,"methodology":"fee schedule"}]}]},{"description":"Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone ","code_information":[{"code":"11012","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Plastic operation on penis for epispadias distal to external sphincter; ","code_information":[{"code":"367","type":"RC"},{"code":"54380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation ","code_information":[{"code":"74235","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; 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"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":984.440,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":984.440,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1003.930,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon ","code_information":[{"code":"26412","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Glassia injection ","code_information":[{"code":"1415","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":5.690,"maximum":8.200,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":5.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":5.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":5.750,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":6.550,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8.200,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":5.860,"methodology":"fee schedule"}]}]},{"description":"Removal of embedded foreign body from dentoalveolar structures; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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 constricting ring of finger, with multiple Z-plasties ","code_information":[{"code":"26596","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"OTHER O.R. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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","code_information":[{"code":"481","type":"RC"},{"code":"67225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC 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for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal ","code_information":[{"code":"490","type":"RC"},{"code":"69801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC ","code_information":[{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2253.120,"maximum":28778.300,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":28778.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":23189.800,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":12026.960,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14414.040,"methodology":"fee schedule"},{"payer_name":"Cigna Evernorth Behavioral Health","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"ComPsych","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"COMM","standard_charge_dollar":20019.380,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2253.120,"methodology":"fee schedule"}]}]},{"description":"Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; initial single probe stain procedure ","code_information":[{"code":"88367","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.110,"maximum":84.110,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":84.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":84.110,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1082.160,"maximum":1103.580,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1082.160,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1082.160,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1082.160,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1103.580,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"44380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision or destruction of lesion of pharynx, any method ","code_information":[{"code":"42808","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Repair recurrent femoral hernia; 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with debridement and partial synovectomy ","code_information":[{"code":"27441","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1876.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Repair blood vessel with graft other than vein; lower extremity ","code_information":[{"code":"35286","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair blood vessel, direct; neck ","code_information":[{"code":"35201","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC ","code_information":[{"code":"171","type":"RC"},{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27643.440,"maximum":33128.250,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":27643.440,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":33128.250,"methodology":"fee schedule"}]}]},{"description":"Lysis of labial adhesions ","code_information":[{"code":"360","type":"RC"},{"code":"56441","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for ","code_information":[{"code":"29826","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":1714.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) ","code_information":[{"code":"20220","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; intermediate ","code_information":[{"code":"77285","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":712.710,"maximum":712.710,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":712.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":712.710,"methodology":"fee schedule"}]}]},{"description":"Peritoneal lavage, including imaging guidance, when performed ","code_information":[{"code":"361","type":"RC"},{"code":"49084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"PSYCHOSES ","code_information":[{"code":"174","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11879.480,"maximum":14236.520,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":11879.480,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":14236.520,"methodology":"fee schedule"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation ","code_information":[{"code":"360","type":"RC"},{"code":"67040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Removal or repair of electromagnetic bone conduction hearing device in temporal bone ","code_information":[{"code":"369","type":"RC"},{"code":"69711","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component ","code_information":[{"code":"23334","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22700.030,"maximum":27204.010,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":22700.030,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":27204.010,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex ","code_information":[{"code":"25107","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, forearm or wrist ","code_information":[{"code":"25999","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"OTHER O.R. 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without anesthesia ","code_information":[{"code":"27560","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve ","code_information":[{"code":"31243","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5050.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach ","code_information":[{"code":"490","type":"RC"},{"code":"58615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS ","code_information":[{"code":"170","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":60552.840,"maximum":72567.290,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":60552.840,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":72567.290,"methodology":"fee schedule"}]}]},{"description":"Tympanic neurectomy ","code_information":[{"code":"490","type":"RC"},{"code":"69676","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Cystotomy; 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multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1876.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2559.000,"methodology":"case rate"}]}]},{"description":"Plastic operation on penis for epispadias distal to external sphincter; with incontinence ","code_information":[{"code":"490","type":"RC"},{"code":"54385","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright 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may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CONCUSSION WITHOUT CC/MCC ","code_information":[{"code":"090","type":"MS-DRG"},{"code":"179","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":8127.150,"maximum":9739.680,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":8127.150,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":9739.680,"methodology":"fee schedule"}]}]},{"description":"PLEURAL EFFUSION WITH CC ","code_information":[{"code":"170","type":"RC"},{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8661.830,"maximum":10380.450,"payers_information":[{"payer_name":"Bright 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for multiple procedure logic."}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH CC ","code_information":[{"code":"174","type":"RC"},{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17423.650,"maximum":20880.720,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":17423.650,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":20880.720,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) ","code_information":[{"code":"362","type":"RC"},{"code":"43232","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1010.790,"maximum":1162.410,"payers_information":[{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":1162.410,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1010.790,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1010.790,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair ","code_information":[{"code":"40810","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures ","code_information":[{"code":"44406","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, 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","code_information":[{"code":"23412","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3723.000,"maximum":10746.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":10746.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":8418.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":3723.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":5078.000,"methodology":"case rate"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 horizontal muscles 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","code_information":[{"code":"25100","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any 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","code_information":[{"code":"20561","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical ","code_information":[{"code":"22100","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial 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","code_information":[{"code":"0629T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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) 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each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code f ","code_information":[{"code":"15272","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed) ","code_information":[{"code":"480","type":"RC"},{"code":"64487","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11404","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FIXATION OF TONGUE, MECHANICAL, OTHER THAN SUTURE (EG, K-WIRE) ","code_information":[{"code":"41500","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":7602.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":7602.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5956.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space ","code_information":[{"code":"41009","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"144","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1530.080,"maximum":1560.370,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":1530.080,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":1530.080,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":1530.080,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":1560.370,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Tenolysis, flexor tendon; palm AND finger, each tendon ","code_information":[{"code":"26442","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Imiglucerase injection ","code_information":[{"code":"1327","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":43.230,"maximum":62.250,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":43.660,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":43.660,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":43.660,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":49.720,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"DualEligible","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPOS","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":43.230,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":62.250,"methodology":"fee schedule"},{"payer_name":"Zing","plan_name":"MGMCR","standard_charge_dollar":44.530,"methodology":"fee schedule"}]}]},{"description":"Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen ","code_information":[{"code":"36596","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1804.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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 up to 100 sq cm; first 25 sq ","code_information":[{"code":"369","type":"RC"},{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1235.060,"maximum":1420.320,"payers_information":[{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":1420.320,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":1235.060,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1235.060,"methodology":"fee schedule","additional_payer_notes":"Days 3. 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","code_information":[{"code":"360","type":"RC"},{"code":"64840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":870.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":870.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1187.000,"methodology":"case rate"}]}]},{"description":"Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 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adjusted for multiple procedure logic."}]}]},{"description":"Telisotuzumab vedotin-tll ","code_information":[{"code":"894","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":145.870,"maximum":210.050,"payers_information":[{"payer_name":"Aetna","plan_name":"MGMCRHMO","standard_charge_dollar":147.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRPPO","standard_charge_dollar":147.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MGMCRSNP","standard_charge_dollar":147.330,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MGMCR","standard_charge_dollar":145.870,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"MCRNarrow","standard_charge_dollar":167.750,"methodology":"fee schedule"},{"payer_name":"Devoted Health Plan","plan_name":"MCR","standard_charge_dollar":145.870,"methodology":"fee 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","code_information":[{"code":"499","type":"RC"},{"code":"56501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) 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"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9276.500,"maximum":11117.070,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":9276.500,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":11117.070,"methodology":"fee schedule"}]}]},{"description":"Injection of air or contrast into peritoneal cavity (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"49400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater ","code_information":[{"code":"21554","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal ","code_information":[{"code":"362","type":"RC"},{"code":"49407","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. 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"}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC ","code_information":[{"code":"173","type":"RC"},{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14092.970,"maximum":16889.200,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":14092.970,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":16889.200,"methodology":"fee schedule"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"143","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":30067.330,"maximum":36033.070,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":30067.330,"methodology":"fee schedule"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":36033.070,"methodology":"fee schedule"}]}]},{"description":"Carpectomy; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Magellan Behavioral Health","plan_name":"MCR","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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with fistulectomy, including fissurectomy, when performed ","code_information":[{"code":"46262","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1471.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1471.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":2007.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of lunate dislocation, with manipulation ","code_information":[{"code":"25690","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":607.000,"maximum":2303.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":2303.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1804.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":607.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":827.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, wrist, surgical; synovectomy, complete ","code_information":[{"code":"29845","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":1714.000,"payers_information":[{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy) ","code_information":[{"code":"30118","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.000,"maximum":6446.000,"payers_information":[{"payer_name":"Aetna","plan_name":"COMM","standard_charge_dollar":6446.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5050.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Bright Health","plan_name":"HIX","standard_charge_dollar":1257.000,"methodology":"case rate"},{"payer_name":"Bright Health","plan_name":"SmallGroup","standard_charge_dollar":1714.000,"methodology":"case rate"}]}]},{"description":"Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ie